1. Complainant took two loans vide RGL no.19536 and 24670 amounting to Rs. 30,330/- and Rs.39,820/- respectively from opposite party no.2. It is pleaded by the complainant in this complaint under section 12 of the Consumer Protection Act, 1986 that opposite party no.2 has taken insurance policy from opposite party no.1 for a sum of Rs.2,00,000/- under Credit Shield Cover and Rs.5,00,000/-under Personal Accident cover for customers obtaining personal loan from them (OP No.2). Master policy no. is 83001000909. But terms and conditions of the policy have not been made available by opposite party no.1 or 2 to the complainant till now. Premium of insurance has been obtained by opposite party no.2 from the complainant as the same is added in equal monthly instalments. There is arrangement between opposite party no.1 and 2 qua insurance business and to cover personal accidental risk and Credit Shield Cover of the loanees, as such, opposite party no.2 has acted as an agent of opposite party no.1, so far the insurance cover is concerned. While obtaining the loan, opposite party no.2 issued insurance certificate to the complainant insuring him for Rs.2,00,000/- under Credit Shield Cover and Rs.5,00,000/- under personal accident cover, subject to terms and conditions of the master policy. Complainant met with road accident on 28.3.2005, received multiple grievous injuries resulting in total and permanent disability equivalent to 80%. Left leg of the complainant was amputated, his right hip bone had fractured. Complainant, as such, is unable to move due to accidental injury and was unable to repay the loan to opposite party no.2. Under Credit Shield Cover, complainant was entitled for Rs.4,00,000/-, as Rs.2,00,000/- each against personal loans and Rs.10,000/- under personal accident insurance cover. So, opposite party no.2 was prayed to waive off the loan instalments and that the insurance coverage amount under Credit Shield Cover be paid. Necessary documents for making payment of the insurance were given. Thereafter, approached them several times to settle the claim by paying Rs.10,00,000/- under personal accident but they paid no heed thereto. Same is claimed to be deficiency in service on the part of opposite parties and sought directions against opposite party no.1 to pay personal accidental insurance claim of Rs.10,00,000/- to the complainant and pay balance loan outstanding in his both personal loan accounts to opposite party no.2 under the Credit Shield Cover obtained form opposite party no.1. Also direction has been sought against opposite party no.1 not to recover balance outstanding against his loan accounts. In addition, sought compensation of Rs.1,00,000/- for harassment caused due to deficiency in service.

2. Opposite party no.1-Insurance Company in reply pleaded that the policy is issued by them to the individual in case of obtaining individual insurance from them. But in case of group schemes, Group is the Policy holder, namely financial institution, the borrowers of which or bank account holders are covered under the Group Scheme. Such group, bank or financial institution, submit single proposal on behalf of all the eligible members of the group and the group is assessed to risk and master policy covering all eligible members is issued to the group policy holder. Therein, all terms and conditions of the contract are incorporated and those are binding on the group policy holder, members of the group and the insurer. Under master policy, certificate of insurance is only issued. They admitted that they have purchased insurance scheme for the borrower of the personal loan from the opposite party no.2. On the date of death of borrower, maximum Rs.2,00,000/- under the Credit Shield Cover and an amount of Rs.5,00,000/- in case of death or total or permanent disability suffered by the borrower as a result of accident under personal accident cover, is provided. Conceded that the complainant had taken two personal loans from opposite party no.2, who had issued insurance certificate to him. They averred that claim of the complainant was bonafidely repudiated strictly in accordance with terms and conditions of the master policy. Complaint is false, untenable and not maintainable. Complainant had not suffered permanent disability of both limbs, so, his case does not fall under the definition of TDP under master policy. Therefore, the claim was rightly rejected. It is denied that the complainant met with an accident on 28.3.2005 and suffered injuries. Complainant for the first time was admitted in the nursing home on 28.6.2005 after three months of alleged accident receiving injuries. Complainant was chronic diabetic, was on insulin. There is no proof of accident dated 28.3.2005. Hence, he never met with an accident on that day nor suffered injuries. There is no deficiency in service on the part of opposite party and the claim was rightly rejected as it was not maintainable.

3. Opposite party no.2 by separate reply pleaded that the complainant has no cause of action against them nor there is any deficiency in service on their part. They admitted obtaining loan from them by the complainant and it was inclusive of premium amount for taking the insurance. Insurance premium amount was transferred to opposite party no.1. They have acted only as sourcing company to forward the premium amount for the insurance of the complainant. Insurance certificate was issued by opposite party no.1 and not by them. They were not responsible for issuance of insurance policy nor under any obligation to do so. They have feigned ignorance about accident of the complainant, suffering of injuries in such accident. Hence, denied occurring of accident for want of knowledge. Claim against them is baseless. Complainant is not entitled for any adjustment of balance outstanding against his loan nor they are bound to pay any insurance money to the complainant. They have no role to play in this behalf. There is also no deficiency or negligence on their part and the complaint is liable to be dismissed.

4. Both the parties, in order to prove their respective versions, have led their evidence by way of affidavits and documents.

5. We have heard the arguments addressed by the ld. counsel for the parties and have gone through the file and scanned the documents and other material on record.

6. First and foremost question attracting our attention to dispose the complaint is whether complainant suffered accidental injuries, due to which his one leg was amputated.

7. Before we touch upon the controversy, would prefer to record outrightly that taking of personal loan by the complainant from opposite party no.2 and consequently getting insurance coverage are undisputed and admitted aspects of the case. Therefore, we shall not burden the record unnecessarily by referring material qua these admitted aspects.

8. Ex.C.2 and C3 are certificate of insurance issued by opposite party no.1 to the complainant. Title of both these certificates is relevant for understanding the controversy. Hence, we are reproducing the same as under:

“We hereby certify that the holder* of this certificate, is insured for an amount upto Rs.2,00,000/-* under the Credit Shield Cover and upto Rs.5,00,000/-** under the Personal Accident Cover subject to the terms and conditions contained in the Master Policy issued to GE Countrywide Consumer Financial Services Limited. ”

9. In support of his claim with opposite party, complainant has submitted applications Ex.C.6 and C7 to Claims Administration of opposite party no.1 along with medical certificate Ex.C.8, C9, C10, C11, discharge summary Ex.C.13, invoice Ex.C15 and disability certificate Ex.C.16. In addition, filed copy of the certificate of disability Ex.C.18 and Form of Concession Certificate for rail concession Ex.C.17. Now grouse of the complainant is that despite his request and issuance of notice Ex.C.4, claim has not been paid by opposite party no.2.

10. It is in such scenario to be reckoned whether complainant suffered permanent disability in an accident, so as to empower him for insurance claim due to such disability suffered in an accident. We may say that as per allegations of the complainant, accident had taken place on 28.3.2005, wherein received multiple and grievous injuries. Qua such accident, no report with the police was lodged, nor any entry in DDR or any police station or police post was made. How and in what circumstances, such road accident occurred, nothing is spelled by the complainant in his pleadings. Also no treatment for receiving multiple and grievous injuries in such an accident dated 28.3.2005 , was ever taken in any hospital/nursing home/ dispensary or any medical institution, immediately after such accident. It is in such scenario to be seen, whether injuries leading to amputation of left leg of the complainant had any relation with accident allegedly occurred on 28.3.2005.

11. Discharge summary Ex.C.13 of Bagga Nursing Home, Ludhiana appended by the complainant with his claim application shows that he got admission in the nursing home on 28.6.2005 and remained as indoor patient upto 12.7.2005. It is mentioned in the discharge summary that the patient is known diabetic and was on help of injection insulin in hospital and before hospitalization he was on anti-biotic drugs. In history mentioned that the patient was admitted complaint of wound on left foot and heel due to RSA –CH/o three months back, for which was taking treatment as OPD patient. Also recorded that infection increased inspite of treatment for the same. Amputation was done above ankle joint on 7.7.2005.

12. When certainly a person like complainant, who was a known diabetic, suffered injuries in a road accident on 28.3.2005 and that injuries were of grievous and of multiple nature, it can not believed that he took no treatment for such injuries in any medical institution or hospital. If taken, record not produced. Hence, non production of such record make us to infer under section 114 of Evidence Act that no such treatment was taken immediately after so called accident dated 28.3.2005 by the complainant. He for the first time got admission in Bagga Nursing Home on 28.6.2005, after three months of the alleged accident on account of trauma of left food which was full of infection and consequently had to be amputated above the ankle joint on 7.7.2005.

13. Doubt so created on account of non lodging report of FIR qua road accident and not taking immediately treatment in the hospital despite suffering serious injuries, is strengthened from medical record Ex.C.16 dated 16.11.2006 of Gurdev Hospital, Ludhiana. This certificate reads as under:

“This is to certify that Mr. Surjit Singh, 56 years of age, sustained fracture neck of right femur in 1981. Following this he underwent multiple operations. He was seen by me in 2003 when he had sub-trochanteric non-union with stiff hip on the right side and by this time he was detected to be a diabetic. He underwent surgery for his non union at Gurdev Hospital on 26.7.2003, in June 2005 he was admitted at another hospital with severe infection of left leg of three months duration following an accident. His left leg had to be amputated on July 2005 because of Gangrene and infection. His right sub trochonteric fracture has also not united. He is now not able to move on his own and can not put weight on either of his lower limbs. He needs help and support for ambulation”

14. It is as such apparent that complainant in the year 1981 has suffered fracture of neck of right femur for which underwent multiple operations. In 2003, he was detected to be diabetic when was examined for non union with stiff hip on the right side. So, then went for surgery of non union in Gurdev Hospital on 26.7.2003. In June 2005 was admitted in another hospital with severe infection of left leg of three months duration following an accident leading to amputation of leg due to Gangrene and infection. So, theory of accident and suffering multiple grievous injuries in such accident on 28.3.2005 consequently is not believable. So, we conclude that the complainant has not been able to convince us that had met with an accident in March 2005 and received multiple grievous injuries in such accident leading to amputation of leg in July 2005.

15. Annexure 1 is copy of the master policy of Group Insurance Scheme of the opposite party no.1. As per condition no.7.1.3, a person holding the policy would only be entitled for benefit, if suffered permanent disability in an accident caused by outward, violent and visible means and such injury is total and permanent. In the instant case, suffering of permanent total injury in an accident is not established. So, complainant under the group insurance certificate is not entitled for amount of insurance.

16. So far as any payment of the complainant qua Credit Shield Cover, granted under Master Policy is concerned, it is admitted by opposite party no.1 in para 6.2 of the reply that this policy is for sum equivalent to the outstanding loan as on the date of death of the insured Member, but not exceeding Rs. two lacs and not for absolute sum of Rs.2,00,000/-. That policy also cover the risk in case of death only. Therefore, under both the policies, complainant is not entitled for any relief. His claim has rightly been repudiated by the opposite parties. Hence, finding no merit the complaint is dismissed.

1. This is a complaint filed under Section 12 of the Consumer Protection act, 1986 seeking for a direction to the opposite parties to (a) pay a sum of Rs.1,00,000/- being the claim made on policy No.82001002208 issued in favour of the deceased insured Gedela Demudamma, (b) to pay interest thereon at 24% per annum from 28-01-2006 the date of intimation till the date of realization, (c) to pay Rs.10,000/- towards compensation for the mental agony and hardship suffered by the complainant and (d) to pay costs.

2. Briefly, the complainant’s case is that he is brother of one Gedela Demudamma, W/o Swamy Naidu. She had availed credit vide crop loan Account No.01670862870 from the 2nd opposite party on 28-09-2005. The said loan had the benefit of Suraksha Group Insurance for Rs.1,00,000/- which is approved by opposite party No.1 through the 2nd opposite party vide policy No.82001002208. That the complainant is nominee of the insured. The insured was hale and healthy but she developed heart pain suddenly on 23-01-2006. She was shifted to the Community Health Centre, S.Kota where she died due to cardio respiratory arrest. The complainant submitted claim enclosing all the necessary documents but after a long lapse of seven months, opposite party No.2 rejected the claim on untenable grounds. That the deceased had no pre-existing disease and there is no suppression of any such disease. That the rejection of claim is deficiency of service.

3. Opposite party No.1 filed written statement admitting the fact that the deceased Gedela Demudamma had applied for S.B.H. Depositors Scheme under Master Policy, No.82001002208. Rest of the complaint allegations are denied. It is contended that she submitted a proposal form in that connection wherein she had declared that she was in good health but not suffering from any physical deformity or critical illness requiring medical treatment for a critical illness. Basing on the said declaration, she was covered under the S.B.H. depositors Scheme for a sum of Rs.50,000/-. That in fact the deceased Demudamma was suffering from Dilated Cardiomyopathy, PAH, Multiple Ventricular Ectopics, Ischemic Heart Disease since 1994 but suppressed the said fact. That the suppression of material information is fatal as such the contract of insurance is a nullity and void ab-initio. That the enquiry made by opposite party No.1 revealed, the deceased Demudamma had undergone treatment after several tests. That the repudiation of claim is fully justified and there is no deficiency of service. That the complaint is not maintainable. Therefore prayed to dismiss the complaint with costs.

4. Opposite party No.2 filed counter denying the material allegations. It is contended that the documents supplied by the complainant were sent to opposite party No.1 promptly by opposite party No.2. Basing on the material available, opposite party No.1 repudiated the claim since the insured gave a false declaration about her state of health by suppressing real facts. That there is no deficiency of service. Therefore, prayed to dismiss the complaint.

5. The complainant filed his evidence affidavit and marked Exs.A.1 to A.7. Opposite party No.1 filed affidavit and marked Exs.B.1 to B.6. Heard both sides. Perused the affidavits and documents. The point for consideration is: Whether there is deficiency of service?

6. POINT:- Admitted facts are that the deceased G.Demudamma herein after referred to as the insured, was covered under the Master Policy and the complainant is shown as her nominee. So also there is no dispute the policy was in force when the insured died. The reason for rejection of the claim as per Ex.A.6 is, “Late Gedela Demudamma was suffering from Dialted Cardiomyopathy i.e., heart ailment prior to the date of enrolment of policy. That the life assured had concealed material facts at the time of entry into the scheme. The cause of death is directly attributable to the pre-existing medical condition of the deceased at the time of enrolment under the scheme and since the policy does not cover deaths due to pre existing illness, the claim has been rejected”.

7. The burden is on the 1st opposite party to prove that the insured having known that she was suffering from Dialated Cardiomyopathy, PHA, Multiple Ventricular, Ectopics and Ischemic a heart disease from 1994 but suppressed the said fact by giving a false declaration that she possessed good health and never suffered any critical illness. In this context it is relevant to peruse Ex.B.2 letter dated 25-09-2005 which is addressed by the insured to the 2nd opposite party. The insured made declaration that “I am in sound health and that I am not suffering from any physical deformity, mental disorder, critical illness or any condition requiring medical treatment for a critical illness as on date.

I have not been hospitalized for a period of more than fifteen consecutive days in the last twelve months”. Therefore, the statement made by the insured is clear that she possessed of sound health and never suffered critical illness prior to 25-09-2005, when the above statement was made. The opposite parties have produced Exs.B.3 to B.6 to substantiate the plea that the insured had undergone treatment for critical illness before obtaining the policy. Ex.B.3 is Xerox copy of Diagnostic Report from the Mediplus Diagnostic Services, Visakhapatnam.

It shows, on 22-12-1994 one Smt G.Demudamma was examined by the said diagnostic services on being referred by one Dr.G.S.R.Murthy, M.D., D.M. The impression of the diagnostic services is that it is a case of Dialated Cardiomyopathy Moderate Mr., and etc. Ex.B.4 is Xerox copy of the observations made by the said Doctor and also mentioned the prescriptions. Ex.B.5 is electrocardiogram report dated 23-12-1994 pertaining to Smt G.Demudamma. This Ex.B.5 is from Dr., Rao’s X-ray Clinic and Nursing Home, Vizianagaram. The impression stated is Antero Lateral Myocardial Insufficiency. These reports Ex.B.3 to B.5 mentioned the name of patient as G.Demudamma. More particulars such as surname, name of the village and name of the husband of the patient are not available. Further the opposite parties have not chosen to file any affidavit of the treating Doctor G.S.R.Murthy or that of Dr.K.Tirumala Prasad who referred the patient to Dr.G.S.R.Murthy. But there is one document which is Ex.B.6 an investigation report from Phantom Detective Agency on the treatment undergone by G.Demudamma. In this report it is mentioned the Detective Agency happened to meet one G.Krishna, S/o Late Swami Naidu.

The deceased insured is G.Demudamma who is Wife of Late Swamy Naidu. Therefore, the said Mr., Krishna who is shown as an advocate at Buchchayapalem, Visakhapatnam made a statement to the Investigating Agency. According to that statement, the insured was staying in his house during the year 1994. She consulted both at Visakhapatnam and Vizianagaram. It is also mentioned that the deceased was treated by Doctors for the Cardio Myopathy. We are of the sincere opinion, that Mr.G.Krishna who is a practicing advocate is a material witness. He is no other than one of the sons of the insured. He could have filed his affidavit denying the observations made in Ex.B.6 by the Detective Agency. But the complainant did not choose to file any affidavit of the said G.Krishna. We are also doubtful about the personal knowledge of the complainant about the details of the health problems of his sister which is the insured since he is not a member of the family of the insured. Added to this, Ex.A.5 Medical Attendant’s Certificate shows that the primary cause of death was heart failure. The insured had heart complaint during the year 1994 and later she died of the same complaint. Thus from the material available on record, we hold that it is a case of suppression of true state of health by the insured at the time of the proposal. Accordingly we hold there is no deficiency of service. Accordingly this point is answered.

8. In the result, the complaint is dismissed. Each party to bear its own costs.

2. The brief facts of the complaint is as follows:- The husband of the complainant by name D. Kesavulu was working as Station Manager, South Central Railway, Chennai Division availed a housing loan of Rs. 5,95,000/- on 8-2-2006 under A/c No. 30035932791 from R3 branch. On the same day D. Kesavulu deposited Rs. 41,899/- and joined as a member in S.B.I Life Insurance Super Suraksha scheme. It was for the borrowers of housing loans. In case of death of the policy holder or member of the scheme the debt should be wiped of and the documents deposited should be returned. It came into effect from 20-2-2008. Kesavulu was issued one HL/180457 bond by S.B.I Life insurance Super Suraksha scheme. The scheme was administered by R3. Kesavulu died due to heart attack at Kadapa on 8-2-2007 and the same was informed to R3. R3 sent claim forms to the complainant.

They were submitted along with documents and the original insurance certificate. The complainant requested the respondents to wipe of the housing loan of her deceased husband and further requested to return the documents deposited by her deceased husband. But the respondents did not respond. On 21-11-2007 the R3 issued a loan status statement demanding the outstanding balance due to the bank. Later the son of the complainant and the complainant approached the R3, who informed that the company would settle the claim. But it was not settled. In January 2008, the complainant again approached the R3 about the loan and return of the documents.

As there was no reply she got issued a notice dt. 10-9-2008 to R3 and again on 25-9-2008 to R2 and R3. There was no response. On 17-12-2008 the complainant made a complaint to permanent Lok Adalath, Kadapa and registered as complaint No. 104/2008. The permanent Lok Adalath, Kadapa closed the case on the ground that raised by R3 that the permanent Lokadalath had no jurisdiction. The R3 sent a notice dt. 22-2-2009 demanding to pay Rs. 1,22,145/- towards 15 installments. Thus the present complaint was filed for directing R1 & R2 to repay the loan, to R3 and to return the documents and Rs. 2,00,000/- towards mental agony.

3. The O.P No. 1 & O.P. No. 2 filed a counter adopted by O.P. No. 3 with a memo. There were money issues to be decided by the Civil Court and not by District Forum because they were summary proceedings. The contract was under utmost good faith to which the proposer should disclose correct facts about his health, age and habits failing which the insurer had right to repudiate the claim.

The insured in the instant case committed a breach of principle of utmost good faith by suppression of material facts of his pre-existing illness of heart disease, hyper tension and diabetes. He signed in the declaration of good heath but committed breach of it. The deceased was suffering from heart disease, hyper tension and diabetes before signing in the proposal form for entering in the contract with insurance company. Thus the O.P No. 1 and 2 repudiated the claim. He did not disclose the real facts. Hence, the insured committed fraud to obtain insurance cover by suppressing the real facts of his pre-existing diseases. Under section 17 of Indian contract Act the contract was void and there was no enforcement to contract.

4. The deceased life assured (DLA) namely D. Kesavulu submitted a proposal form dt. 20-2-2006 for Master policy No. 83001000203. The sum assured would be the outstanding loan amount as on the date of death as per original schedule. The consent – cum - authorization – cum – Good heath declaration form (DGH) was basis of risk assessment and was the document for the contract.

The insured i.e. the Deceased Life Assured declared that he was in sound health and had no physical deformity and never suffered or suffering or hospitalized at any time. Critical illness was shown as heart disease and cancer etc., He had undergone tests also. Heart disease was a critical illness excluded in the proposal form. The insured concealed the pre-existing illness of heart disease, diabetes and hyper tension. Had it be known earlier the insurance cover would not be offered by O.P. No. 1 & 2 and declined the proposal. The insurance cover was obtained by suppressing the material facts.

5. The insured died on 8-2-2007. The investigation report revealed that the insured was a known heart disease patient. It was known from the office records of RIMS, Kadapa, dt. 10-5-2005 and 8-2-2006. The Medical attendance certificate also disclosed the heart disease even prior to admission into the scheme of insurance.

The hospital records was clear that the he was suffering from heart disease, hyper tension and diabetes. The insured gave declaration also in the proposal form under point 14-B in schedule 4 of Master policy bond. In case incorrect and untrue statements and suppression of material facts had been given the policy would become null and void. The claims review committee confirmed the repudiation of the claim by way of letter dt. 12-12-2008. The deceased was a known heart ailment patient. All other averments in toto were denied.

6. On the basis of the above pleadings the following points are settled for determination.

i. Whether there is any negligence and deficiency of service on the part of the Opposite parties?

ii. Whether the complainant is entitled to the relief as prayed for?

iii. To what relief?

7. On behalf of the complainant Ex. A1 to A13 were marked and on behalf of the respondent Ex. B1 to B8 were marked.

8. Point No. 1 & 2 The complainant was the wife of late D. Kesavulu, who was working as Station Master, Sough Central Railway, Chennai Division died on 8-2-2007. The cause of death as per complaint was heart disease. During the life time, the deceased Kesavulu availed a housing loan of Rs. 5,95,000/- on 8-2-2006 under A/c No. 30035932791 from R3 and deposited on the same day of Rs. 41,899/- towards membership in SBI Life Super Suraksha Scheme. The said scheme was exclusively for persons availed housing loan from SBI. Under the scheme in case of death of the policy holder or the member the housing loan should be wiped off and the documents deposited by borrower should be returned.

The deceased Kesavulu was allotted HL/180467 and bond was issued under Super Suraksha scheme. The Xerox copy of said bond was filed under Ex. A1. Ex. A1 disclosed the A/c No. and loan amount and gross premium. It was issued on 23-2-2006 with the terms and conditions of the scheme. Under Ex. A1 the borrower should give a declaration of good health in a prescribed form and should not have suffered from cancer, condition requiring open chest surgery, history of typical chest pain, kidney failure, brain stroke or paralysis or having undergone major organ transplantation such as heart, lung, liver or kidney.

9. The housing loan borrower D. Kesavulu died on 8-2-2007 due to heart attack at kadapa in his house as per complaint. After his death the R3 issued a letter dt. 21-11-2007 regarding outstanding balance due of Rs. 6,23,466/- and mentioned that the payments were irregular. The Xerox copy of letter was Ex. A2 along with copy of statement of account. On 10-9-2008, the complainant got issued a notice to R3. The office copy of the notice was Ex. A3. Ex. A4 was Xerox copy of another letter from complainant to R2 & R3. Ex. A5 were two postal acknowledgements.

10. After the death of her husband the complainant submitted a claim statement to respondents. Ex. A6 was Xerox copy of claimant statement. Subsequently the complainant represented her case to the permanent Lokadalath, Kadapa by way of written representation to which the R3 informed the Permanent Lokadalath that the bank was not willing for immediate settlement because the claim application was resubmitted for reconsideration. The certified copy of the letter of R3 submitted to the permanent Lok adalath, Kadapa dt. 17-12-2008 was Ex. A8. On the same day the permanent Lok Adalath closed the petition i.e. PLAC No. 104/2008. So it was not decided on merits it was simply closed on the ground that the PLA had no jurisdiction and bank was not willing for settlement.

The certified copy of the docket order of PLA was Ex. A7. On 22-1-2009 the R3 wrote another letter with outstanding balance due and housing loan and default instalments. The Xerox copy of letter was Ex. A9. The complainant filed Ex. A10 a copy of letter issued by Station Superintendent, Tirumalapur regarding the duty particulars of the deceased as on 10-5-2005 and also issued another letter under Ex. A11 that he was on duty on 8-2-2006. Ex. A12 was Xerox copy of attendance register of April and May 2005 of the deceased Kesavulu. Ex A13 was Xerox copy of attendance register of January and February 2006.

11. On the other hand the opposite parties also filed Ex. B1 a copy of the Home loan insurance – Master policy issued to the deceased Kesavulu. Ex. B2 and Ex. A1 were one and same. The opposite parties contended that Kesavulu was suffering from heart aliment, diabetes and hyper tension even prior to taking housing loan and suppressed the material facts and hence, the complainant was not entitled to any relief. The opposite parties filed Ex. B4, B5 the Xerox copies of out patient tickets issued by RIMS Hospital, Kadapa on 10-5-2005 and 20-6-2005, 8-2-2006 with diseases of hyper tension, diabetes and coronary artillery diseases (CAD). The same was investigated by private investigation namely Satyam Investigations, Hyderabad.

The copy of the Sathyam Investigations report was Ex. B3. The Xerox copy of medical attendance certificate was Ex. B6 which was disclosed that Kesavulu died due to Ischemic heart disease on 8-2-2007. The deceased gave a declaration at the time of availing the loan that he was in good health. The Xerox copy of the declaration was Ex. B7 called consent – cum – authorization – cum – good health declaration dt. 20-2-2006. By the date of Ex. B7 the deceased was suffering from heart aliment, diabetes and hyper tension as shown in Ex. B4 and B5. So before taking housing loan the deceased was suffering from the said diseases as on 10-5-2005.

The housing loan was availed on 8-2-2006. Therefore, knowing fully well about his health condition that too suffering from heart aliment, diabetes and hyper tension, the deceased suppressed the facts and availed the housing loan and hence, the opposite parties have decided to repudiate the claim. The Xerox copy of the repudiation letter was Ex. B8. There was likelihood of putting signatures in attendance register subsequently on 10-5-2005 and 8-2-2006 by the deceased in Ex. A12 and Ex. A13. On that basis Ex. A10 and A11 might have obtained for the claim. As per Ex. B4 the deceased took treatment on 20-5-2005 also.

12. Therefore, the deceased Kesavulu suppressed the material facts of his health, but availed the loan. Thus there was no deficiency of service on the part of the opposite parties. The opposite parties proved the repudiation by way of Ex. B4 and B5. There was no contrary evidence from the complainant for Ex. B4 and b5 and there was no proper documentary proof from the complainant that the deceased was in good heath on the date of availing the loan. Thus the points are answered accordingly.

13. Point No. 3 In the result, the complaint is dismissed without costs.

2. The brief facts of the complaint is as follows:- The husband of the complainant by name D. Kesavulu was working as Station Manager, South Central Railway, Chennai Division availed a housing loan of Rs. 5,95,000/- on 8-2-2006 under A/c No. 30035932791 from R3 branch. On the same day D. Kesavulu deposited Rs. 41,899/- and joined as a member in S.B.I Life Insurance Super Suraksha scheme. It was for the borrowers of housing loans. In case of death of the policy holder or member of the scheme the debt should be wiped of and the documents deposited should be returned. It came into effect from 20-2-2008. Kesavulu was issued one HL/180457 bond by S.B.I Life insurance Super Suraksha scheme.

The scheme was administered by R3. Kesavulu died due to heart attack at Kadapa on 8-2-2007 and the same was informed to R3. R3 sent claim forms to the complainant. They were submitted along with documents and the original insurance certificate. The complainant requested the respondents to wipe of the housing loan of her deceased husband and further requested to return the documents deposited by her deceased husband. But the respondents did not respond. On 21-11-2007 the R3 issued a loan status statement demanding the outstanding balance due to the bank. Later the son of the complainant and the complainant approached the R3, who informed that the company would settle the claim. But it was not settled. In January 2008, the complainant again approached the R3 about the loan and return of the documents. As there was no reply she got issued a notice dt. 10-9-2008 to R3 and again on 25-9-2008 to R2 and R3.

There was no response. On 17-12-2008 the complainant made a complaint to permanent Lok Adalath, Kadapa and registered as complaint No. 104/2008. The permanent Lok Adalath, Kadapa closed the case on the ground that raised by R3 that the permanent Lokadalath had no jurisdiction. The R3 sent a notice dt. 22-2-2009 demanding to pay Rs. 1,22,145/- towards 15 installments. Thus the present complaint was filed for directing R1 & R2 to repay the loan, to R3 and to return the documents and Rs. 2,00,000/- towards mental agony.

3. The O.P No. 1 & O.P. No. 2 filed a counter adopted by O.P. No. 3 with a memo. There were money issues to be decided by the Civil Court and not by District Forum because they were summary proceedings. The contract was under utmost good faith to which the proposer should disclose correct facts about his health, age and habits failing which the insurer had right to repudiate the claim. The insured in the instant case committed a breach of principle of utmost good faith by suppression of material facts of his pre-existing illness of heart disease, hyper tension and diabetes. He signed in the declaration of good heath but committed breach of it.

The deceased was suffering from heart disease, hyper tension and diabetes before signing in the proposal form for entering in the contract with insurance company. Thus the O.P No. 1 and 2 repudiated the claim. He did not disclose the real facts. Hence, the insured committed fraud to obtain insurance cover by suppressing the real facts of his pre-existing diseases. Under section 17 of Indian contract Act the contract was void and there was no enforcement to contract.

4. The deceased life assured (DLA) namely D. Kesavulu submitted a proposal form dt. 20-2-2006 for Master policy No. 83001000203. The sum assured would be the outstanding loan amount as on the date of death as per original schedule. The consent – cum - authorization – cum – Good heath declaration form (DGH) was basis of risk assessment and was the document for the contract. The insured i.e. the Deceased Life Assured declared that he was in sound health and had no physical deformity and never suffered or suffering or hospitalized at any time. Critical illness was shown as heart disease and cancer etc., He had undergone tests also. Heart disease was a critical illness excluded in the proposal form. The insured concealed the pre-existing illness of heart disease, diabetes and hyper tension. Had it be known earlier the insurance cover would not be offered by O.P. No. 1 & 2 and declined the proposal. The insurance cover was obtained by suppressing the material facts.

5. The insured died on 8-2-2007. The investigation report revealed that the insured was a known heart disease patient. It was known from the office records of RIMS, Kadapa, dt. 10-5-2005 and 8-2-2006. The Medical attendance certificate also disclosed the heart disease even prior to admission into the scheme of insurance. The hospital records was clear that the he was suffering from heart disease, hyper tension and diabetes. The insured gave declaration also in the proposal form under point 14-B in schedule 4 of Master policy bond. In case incorrect and untrue statements and suppression of material facts had been given the policy would become null and void. The claims review committee confirmed the repudiation of the claim by way of letter dt. 12-12-2008. The deceased was a known heart ailment patient. All other averments in toto were denied.

6. On the basis of the above pleadings the following points are settled for determination.

i. Whether there is any negligence and deficiency of service on the part of the Opposite parties?

ii. Whether the complainant is entitled to the relief as prayed for?

iii. To what relief?

7. On behalf of the complainant Ex. A1 to A13 were marked and on behalf of the respondent Ex. B1 to B8 were marked.

8. Point No. 1 & 2 The complainant was the wife of late D. Kesavulu, who was working as Station Master, Sough Central Railway, Chennai Division died on 8-2-2007. The cause of death as per complaint was heart disease. During the life time, the deceased Kesavulu availed a housing loan of Rs. 5,95,000/- on 8-2-2006 under A/c No. 30035932791 from R3 and deposited on the same day of Rs. 41,899/- towards membership in SBI Life Super Suraksha Scheme. The said scheme was exclusively for persons availed housing loan from SBI. Under the scheme in case of death of the policy holder or the member the housing loan should be wiped off and the documents deposited by borrower should be returned.

The deceased Kesavulu was allotted HL/180467 and bond was issued under Super Suraksha scheme. The Xerox copy of said bond was filed under Ex. A1. Ex. A1 disclosed the A/c No. and loan amount and gross premium. It was issued on 23-2-2006 with the terms and conditions of the scheme. Under Ex. A1 the borrower should give a declaration of good health in a prescribed form and should not have suffered from cancer, condition requiring open chest surgery, history of typical chest pain, kidney failure, brain stroke or paralysis or having undergone major organ transplantation such as heart, lung, liver or kidney.

9. The housing loan borrower D. Kesavulu died on 8-2-2007 due to heart attack at kadapa in his house as per complaint. After his death the R3 issued a letter dt. 21-11-2007 regarding outstanding balance due of Rs. 6,23,466/- and mentioned that the payments were irregular. The Xerox copy of letter was Ex. A2 along with copy of statement of account. On 10-9-2008, the complainant got issued a notice to R3. The office copy of the notice was Ex. A3. Ex. A4 was Xerox copy of another letter from complainant to R2 & R3. Ex. A5 were two postal acknowledgements.

10. After the death of her husband the complainant submitted a claim statement to respondents. Ex. A6 was Xerox copy of claimant statement. Subsequently the complainant represented her case to the permanent Lokadalath, Kadapa by way of written representation to which the R3 informed the Permanent Lokadalath that the bank was not willing for immediate settlement because the claim application was resubmitted for reconsideration. The certified copy of the letter of R3 submitted to the permanent Lok adalath, Kadapa dt. 17-12-2008 was Ex. A8. On the same day the permanent Lok Adalath closed the petition i.e. PLAC No. 104/2008. So it was not decided on merits it was simply closed on the ground that the PLA had no jurisdiction and bank was not willing for settlement.

The certified copy of the docket order of PLA was Ex. A7. On 22-1-2009 the R3 wrote another letter with outstanding balance due and housing loan and default instalments. The Xerox copy of letter was Ex. A9. The complainant filed Ex. A10 a copy of letter issued by Station Superintendent, Tirumalapur regarding the duty particulars of the deceased as on 10-5-2005 and also issued another letter under Ex. A11 that he was on duty on 8-2-2006. Ex. A12 was Xerox copy of attendance register of April and May 2005 of the deceased Kesavulu. Ex A13 was Xerox copy of attendance register of January and February 2006.

11. On the other hand the opposite parties also filed Ex. B1 a copy of the Home loan insurance – Master policy issued to the deceased Kesavulu. Ex. B2 and Ex. A1 were one and same. The opposite parties contended that Kesavulu was suffering from heart aliment, diabetes and hyper tension even prior to taking housing loan and suppressed the material facts and hence, the complainant was not entitled to any relief. The opposite parties filed Ex. B4, B5 the Xerox copies of out patient tickets issued by RIMS Hospital, Kadapa on 10-5-2005 and 20-6-2005, 8-2-2006 with diseases of hyper tension, diabetes and coronary artillery diseases (CAD). The same was investigated by private investigation namely Satyam Investigations, Hyderabad.

The copy of the Sathyam Investigations report was Ex. B3. The Xerox copy of medical attendance certificate was Ex. B6 which was disclosed that Kesavulu died due to Ischemic heart disease on 8-2-2007. The deceased gave a declaration at the time of availing the loan that he was in good health. The Xerox copy of the declaration was Ex. B7 called consent – cum – authorization – cum – good health declaration dt. 20-2-2006. By the date of Ex. B7 the deceased was suffering from heart aliment, diabetes and hyper tension as shown in Ex. B4 and B5. So before taking housing loan the deceased was suffering from the said diseases as on 10-5-2005.

The housing loan was availed on 8-2-2006. Therefore, knowing fully well about his health condition that too suffering from heart aliment, diabetes and hyper tension, the deceased suppressed the facts and availed the housing loan and hence, the opposite parties have decided to repudiate the claim. The Xerox copy of the repudiation letter was Ex. B8. There was likelihood of putting signatures in attendance register subsequently on 10-5-2005 and 8-2-2006 by the deceased in Ex. A12 and Ex. A13. On that basis Ex. A10 and A11 might have obtained for the claim. As per Ex. B4 the deceased took treatment on 20-5-2005 also.

12. Therefore, the deceased Kesavulu suppressed the material facts of his health, but availed the loan. Thus there was no deficiency of service on the part of the opposite parties. The opposite parties proved the repudiation by way of Ex. B4 and B5. There was no contrary evidence from the complainant for Ex. B4 and b5 and there was no proper documentary proof from the complainant that the deceased was in good heath on the date of availing the loan. Thus the points are answered accordingly.

13. Point No. 3 In the result, the complaint is dismissed without costs.

2. The brief facts of the complaint is as follows:- The husband of the complainant by name D. Kesavulu was working as Station Manager, South Central Railway, Chennai Division availed a housing loan of Rs. 5,95,000/- on 8-2-2006 under A/c No. 30035932791 from R3 branch. On the same day D. Kesavulu deposited Rs. 41,899/- and joined as a member in S.B.I Life Insurance Super Suraksha scheme. It was for the borrowers of housing loans. In case of death of the policy holder or member of the scheme the debt should be wiped of and the documents deposited should be returned. It came into effect from 20-2-2008.

Kesavulu was issued one HL/180457 bond by S.B.I Life insurance Super Suraksha scheme. The scheme was administered by R3. Kesavulu died due to heart attack at Kadapa on 8-2-2007 and the same was informed to R3. R3 sent claim forms to the complainant. They were submitted along with documents and the original insurance certificate. The complainant requested the respondents to wipe of the housing loan of her deceased husband and further requested to return the documents deposited by her deceased husband.

But the respondents did not respond. On 21-11-2007 the R3 issued a loan status statement demanding the outstanding balance due to the bank. Later the son of the complainant and the complainant approached the R3, who informed that the company would settle the claim. But it was not settled. In January 2008, the complainant again approached the R3 about the loan and return of the documents. As there was no reply she got issued a notice dt. 10-9-2008 to R3 and again on 25-9-2008 to R2 and R3.

There was no response. On 17-12-2008 the complainant made a complaint to permanent Lok Adalath, Kadapa and registered as complaint No. 104/2008. The permanent Lok Adalath, Kadapa closed the case on the ground that raised by R3 that the permanent Lokadalath had no jurisdiction. The R3 sent a notice dt. 22-2-2009 demanding to pay Rs. 1,22,145/- towards 15 installments. Thus the present complaint was filed for directing R1 & R2 to repay the loan, to R3 and to return the documents and Rs. 2,00,000/- towards mental agony.

3. The O.P No. 1 & O.P. No. 2 filed a counter adopted by O.P. No. 3 with a memo. There were money issues to be decided by the Civil Court and not by District Forum because they were summary proceedings. The contract was under utmost good faith to which the proposer should disclose correct facts about his health, age and habits failing which the insurer had right to repudiate the claim. The insured in the instant case committed a breach of principle of utmost good faith by suppression of material facts of his pre-existing illness of heart disease, hyper tension and diabetes. He signed in the declaration of good heath but committed breach of it.

The deceased was suffering from heart disease, hyper tension and diabetes before signing in the proposal form for entering in the contract with insurance company. Thus the O.P No. 1 and 2 repudiated the claim. He did not disclose the real facts. Hence, the insured committed fraud to obtain insurance cover by suppressing the real facts of his pre-existing diseases. Under section 17 of Indian contract Act the contract was void and there was no enforcement to contract.

4. The deceased life assured (DLA) namely D. Kesavulu submitted a proposal form dt. 20-2-2006 for Master policy No. 83001000203. The sum assured would be the outstanding loan amount as on the date of death as per original schedule. The consent – cum - authorization – cum – Good heath declaration form (DGH) was basis of risk assessment and was the document for the contract.

The insured i.e. the Deceased Life Assured declared that he was in sound health and had no physical deformity and never suffered or suffering or hospitalized at any time. Critical illness was shown as heart disease and cancer etc., He had undergone tests also. Heart disease was a critical illness excluded in the proposal form. The insured concealed the pre-existing illness of heart disease, diabetes and hyper tension. Had it be known earlier the insurance cover would not be offered by O.P. No. 1 & 2 and declined the proposal. The insurance cover was obtained by suppressing the material facts.

5. The insured died on 8-2-2007. The investigation report revealed that the insured was a known heart disease patient. It was known from the office records of RIMS, Kadapa, dt. 10-5-2005 and 8-2-2006. The Medical attendance certificate also disclosed the heart disease even prior to admission into the scheme of insurance. The hospital records was clear that the he was suffering from heart disease, hyper tension and diabetes.

The insured gave declaration also in the proposal form under point 14-B in schedule 4 of Master policy bond. In case incorrect and untrue statements and suppression of material facts had been given the policy would become null and void. The claims review committee confirmed the repudiation of the claim by way of letter dt. 12-12-2008. The deceased was a known heart ailment patient. All other averments in toto were denied.

6. On the basis of the above pleadings the following points are settled for determination.

i. Whether there is any negligence and deficiency of service on the part of the Opposite parties?

ii. Whether the complainant is entitled to the relief as prayed for?

iii. To what relief?

7. On behalf of the complainant Ex. A1 to A13 were marked and on behalf of the respondent Ex. B1 to B8 were marked.

8. Point No. 1 & 2 The complainant was the wife of late D. Kesavulu, who was working as Station Master, Sough Central Railway, Chennai Division died on 8-2-2007. The cause of death as per complaint was heart disease. During the life time, the deceased Kesavulu availed a housing loan of Rs. 5,95,000/- on 8-2-2006 under A/c No. 30035932791 from R3 and deposited on the same day of Rs. 41,899/- towards membership in SBI Life Super Suraksha Scheme. The said scheme was exclusively for persons availed housing loan from SBI. Under the scheme in case of death of the policy holder or the member the housing loan should be wiped off and the documents deposited by borrower should be returned.

The deceased Kesavulu was allotted HL/180467 and bond was issued under Super Suraksha scheme. The Xerox copy of said bond was filed under Ex. A1. Ex. A1 disclosed the A/c No. and loan amount and gross premium. It was issued on 23-2-2006 with the terms and conditions of the scheme. Under Ex. A1 the borrower should give a declaration of good health in a prescribed form and should not have suffered from cancer, condition requiring open chest surgery, history of typical chest pain, kidney failure, brain stroke or paralysis or having undergone major organ transplantation such as heart, lung, liver or kidney.

9. The housing loan borrower D. Kesavulu died on 8-2-2007 due to heart attack at kadapa in his house as per complaint. After his death the R3 issued a letter dt. 21-11-2007 regarding outstanding balance due of Rs. 6,23,466/- and mentioned that the payments were irregular. The Xerox copy of letter was Ex. A2 along with copy of statement of account. On 10-9-2008, the complainant got issued a notice to R3. The office copy of the notice was Ex. A3. Ex. A4 was Xerox copy of another letter from complainant to R2 & R3. Ex. A5 were two postal acknowledgements.

10. After the death of her husband the complainant submitted a claim statement to respondents. Ex. A6 was Xerox copy of claimant statement. Subsequently the complainant represented her case to the permanent Lokadalath, Kadapa by way of written representation to which the R3 informed the Permanent Lokadalath that the bank was not willing for immediate settlement because the claim application was resubmitted for reconsideration.

The certified copy of the letter of R3 submitted to the permanent Lok adalath, Kadapa dt. 17-12-2008 was Ex. A8. On the same day the permanent Lok Adalath closed the petition i.e. PLAC No. 104/2008. So it was not decided on merits it was simply closed on the ground that the PLA had no jurisdiction and bank was not willing for settlement. The certified copy of the docket order of PLA was Ex. A7. On 22-1-2009 the R3 wrote another letter with outstanding balance due and housing loan and default instalments.

The Xerox copy of letter was Ex. A9. The complainant filed Ex. A10 a copy of letter issued by Station Superintendent, Tirumalapur regarding the duty particulars of the deceased as on 10-5-2005 and also issued another letter under Ex. A11 that he was on duty on 8-2-2006. Ex. A12 was Xerox copy of attendance register of April and May 2005 of the deceased Kesavulu. Ex A13 was Xerox copy of attendance register of January and February 2006.

11. On the other hand the opposite parties also filed Ex. B1 a copy of the Home loan insurance – Master policy issued to the deceased Kesavulu. Ex. B2 and Ex. A1 were one and same. The opposite parties contended that Kesavulu was suffering from heart aliment, diabetes and hyper tension even prior to taking housing loan and suppressed the material facts and hence, the complainant was not entitled to any relief. The opposite parties filed Ex. B4, B5 the Xerox copies of out patient tickets issued by RIMS Hospital, Kadapa on 10-5-2005 and 20-6-2005, 8-2-2006 with diseases of hyper tension, diabetes and coronary artillery diseases (CAD). The same was investigated by private investigation namely Satyam Investigations, Hyderabad.

The copy of the Sathyam Investigations report was Ex. B3. The Xerox copy of medical attendance certificate was Ex. B6 which was disclosed that Kesavulu died due to Ischemic heart disease on 8-2-2007. The deceased gave a declaration at the time of availing the loan that he was in good health. The Xerox copy of the declaration was Ex. B7 called consent – cum – authorization – cum – good health declaration dt. 20-2-2006. By the date of Ex. B7 the deceased was suffering from heart aliment, diabetes and hyper tension as shown in Ex. B4 and B5. So before taking housing loan the deceased was suffering from the said diseases as on 10-5-2005.

The housing loan was availed on 8-2-2006. Therefore, knowing fully well about his health condition that too suffering from heart aliment, diabetes and hyper tension, the deceased suppressed the facts and availed the housing loan and hence, the opposite parties have decided to repudiate the claim. The Xerox copy of the repudiation letter was Ex. B8. There was likelihood of putting signatures in attendance register subsequently on 10-5-2005 and 8-2-2006 by the deceased in Ex. A12 and Ex. A13. On that basis Ex. A10 and A11 might have obtained for the claim. As per Ex. B4 the deceased took treatment on 20-5-2005 also.

12. Therefore, the deceased Kesavulu suppressed the material facts of his health, but availed the loan. Thus there was no deficiency of service on the part of the opposite parties. The opposite parties proved the repudiation by way of Ex. B4 and B5. There was no contrary evidence from the complainant for Ex. B4 and b5 and there was no proper documentary proof from the complainant that the deceased was in good heath on the date of availing the loan. Thus the points are answered accordingly.

2. The brief facts of the complaint is as follows:- The husband of the complainant by name D. Kesavulu was working as Station Manager, South Central Railway, Chennai Division availed a housing loan of Rs. 5,95,000/- on 8-2-2006 under A/c No. 30035932791 from R3 branch. On the same day D. Kesavulu deposited Rs. 41,899/- and joined as a member in S.B.I Life Insurance Super Suraksha scheme. It was for the borrowers of housing loans. In case of death of the policy holder or member of the scheme the debt should be wiped of and the documents deposited should be returned. It came into effect from 20-2-2008. Kesavulu was issued one HL/180457 bond by S.B.I Life insurance Super Suraksha scheme. The scheme was administered by R3. Kesavulu died due to heart attack at Kadapa on 8-2-2007 and the same was informed to R3. R3 sent claim forms to the complainant.

They were submitted along with documents and the original insurance certificate. The complainant requested the respondents to wipe of the housing loan of her deceased husband and further requested to return the documents deposited by her deceased husband. But the respondents did not respond. On 21-11-2007 the R3 issued a loan status statement demanding the outstanding balance due to the bank. Later the son of the complainant and the complainant approached the R3, who informed that the company would settle the claim. But it was not settled. In January 2008, the complainant again approached the R3 about the loan and return of the documents.

As there was no reply she got issued a notice dt. 10-9-2008 to R3 and again on 25-9-2008 to R2 and R3. There was no response. On 17-12-2008 the complainant made a complaint to permanent Lok Adalath, Kadapa and registered as complaint No. 104/2008. The permanent Lok Adalath, Kadapa closed the case on the ground that raised by R3 that the permanent Lokadalath had no jurisdiction. The R3 sent a notice dt. 22-2-2009 demanding to pay Rs. 1,22,145/- towards 15 installments. Thus the present complaint was filed for directing R1 & R2 to repay the loan, to R3 and to return the documents and Rs. 2,00,000/- towards mental agony.

3. The O.P No. 1 & O.P. No. 2 filed a counter adopted by O.P. No. 3 with a memo. There were money issues to be decided by the Civil Court and not by District Forum because they were summary proceedings. The contract was under utmost good faith to which the proposer should disclose correct facts about his health, age and habits failing which the insurer had right to repudiate the claim. The insured in the instant case committed a breach of principle of utmost good faith by suppression of material facts of his pre-existing illness of heart disease, hyper tension and diabetes.

He signed in the declaration of good heath but committed breach of it. The deceased was suffering from heart disease, hyper tension and diabetes before signing in the proposal form for entering in the contract with insurance company. Thus the O.P No. 1 and 2 repudiated the claim. He did not disclose the real facts. Hence, the insured committed fraud to obtain insurance cover by suppressing the real facts of his pre-existing diseases. Under section 17 of Indian contract Act the contract was void and there was no enforcement to contract.

4. The deceased life assured (DLA) namely D. Kesavulu submitted a proposal form dt. 20-2-2006 for Master policy No. 83001000203. The sum assured would be the outstanding loan amount as on the date of death as per original schedule. The consent – cum - authorization – cum – Good heath declaration form (DGH) was basis of risk assessment and was the document for the contract. The insured i.e. the Deceased Life Assured declared that he was in sound health and had no physical deformity and never suffered or suffering or hospitalized at any time.

Critical illness was shown as heart disease and cancer etc., He had undergone tests also. Heart disease was a critical illness excluded in the proposal form. The insured concealed the pre-existing illness of heart disease, diabetes and hyper tension. Had it be known earlier the insurance cover would not be offered by O.P. No. 1 & 2 and declined the proposal. The insurance cover was obtained by suppressing the material facts.

5. The insured died on 8-2-2007. The investigation report revealed that the insured was a known heart disease patient. It was known from the office records of RIMS, Kadapa, dt. 10-5-2005 and 8-2-2006. The Medical attendance certificate also disclosed the heart disease even prior to admission into the scheme of insurance. The hospital records was clear that the he was suffering from heart disease, hyper tension and diabetes.

The insured gave declaration also in the proposal form under point 14-B in schedule 4 of Master policy bond. In case incorrect and untrue statements and suppression of material facts had been given the policy would become null and void. The claims review committee confirmed the repudiation of the claim by way of letter dt. 12-12-2008. The deceased was a known heart ailment patient. All other averments in toto were denied.

6. On the basis of the above pleadings the following points are settled for determination.

i. Whether there is any negligence and deficiency of service on the part of the Opposite parties?

ii. Whether the complainant is entitled to the relief as prayed for?

iii. To what relief?

7. On behalf of the complainant Ex. A1 to A13 were marked and on behalf of the respondent Ex. B1 to B8 were marked.

8. Point No. 1 & 2 The complainant was the wife of late D. Kesavulu, who was working as Station Master, Sough Central Railway, Chennai Division died on 8-2-2007. The cause of death as per complaint was heart disease. During the life time, the deceased Kesavulu availed a housing loan of Rs. 5,95,000/- on 8-2-2006 under A/c No. 30035932791 from R3 and deposited on the same day of Rs. 41,899/- towards membership in SBI Life Super Suraksha Scheme. The said scheme was exclusively for persons availed housing loan from SBI. Under the scheme in case of death of the policy holder or the member the housing loan should be wiped off and the documents deposited by borrower should be returned.

The deceased Kesavulu was allotted HL/180467 and bond was issued under Super Suraksha scheme. The Xerox copy of said bond was filed under Ex. A1. Ex. A1 disclosed the A/c No. and loan amount and gross premium. It was issued on 23-2-2006 with the terms and conditions of the scheme. Under Ex. A1 the borrower should give a declaration of good health in a prescribed form and should not have suffered from cancer, condition requiring open chest surgery, history of typical chest pain, kidney failure, brain stroke or paralysis or having undergone major organ transplantation such as heart, lung, liver or kidney.

9. The housing loan borrower D. Kesavulu died on 8-2-2007 due to heart attack at kadapa in his house as per complaint. After his death the R3 issued a letter dt. 21-11-2007 regarding outstanding balance due of Rs. 6,23,466/- and mentioned that the payments were irregular. The Xerox copy of letter was Ex. A2 along with copy of statement of account. On 10-9-2008, the complainant got issued a notice to R3. The office copy of the notice was Ex. A3. Ex. A4 was Xerox copy of another letter from complainant to R2 & R3. Ex. A5 were two postal acknowledgements.

10. After the death of her husband the complainant submitted a claim statement to respondents. Ex. A6 was Xerox copy of claimant statement. Subsequently the complainant represented her case to the permanent Lokadalath, Kadapa by way of written representation to which the R3 informed the Permanent Lokadalath that the bank was not willing for immediate settlement because the claim application was resubmitted for reconsideration. The certified copy of the letter of R3 submitted to the permanent Lok adalath, Kadapa dt. 17-12-2008 was Ex. A8. On the same day the permanent Lok Adalath closed the petition i.e. PLAC No. 104/2008. So it was not decided on merits it was simply closed on the ground that the PLA had no jurisdiction and bank was not willing for settlement.

The certified copy of the docket order of PLA was Ex. A7. On 22-1-2009 the R3 wrote another letter with outstanding balance due and housing loan and default instalments. The Xerox copy of letter was Ex. A9. The complainant filed Ex. A10 a copy of letter issued by Station Superintendent, Tirumalapur regarding the duty particulars of the deceased as on 10-5-2005 and also issued another letter under Ex. A11 that he was on duty on 8-2-2006. Ex. A12 was Xerox copy of attendance register of April and May 2005 of the deceased Kesavulu. Ex A13 was Xerox copy of attendance register of January and February 2006.

11. On the other hand the opposite parties also filed Ex. B1 a copy of the Home loan insurance – Master policy issued to the deceased Kesavulu. Ex. B2 and Ex. A1 were one and same. The opposite parties contended that Kesavulu was suffering from heart aliment, diabetes and hyper tension even prior to taking housing loan and suppressed the material facts and hence, the complainant was not entitled to any relief. The opposite parties filed Ex. B4, B5 the Xerox copies of out patient tickets issued by RIMS Hospital, Kadapa on 10-5-2005 and 20-6-2005, 8-2-2006 with diseases of hyper tension, diabetes and coronary artillery diseases (CAD). The same was investigated by private investigation namely Satyam Investigations, Hyderabad.

The copy of the Sathyam Investigations report was Ex. B3. The Xerox copy of medical attendance certificate was Ex. B6 which was disclosed that Kesavulu died due to Ischemic heart disease on 8-2-2007. The deceased gave a declaration at the time of availing the loan that he was in good health. The Xerox copy of the declaration was Ex. B7 called consent – cum – authorization – cum – good health declaration dt. 20-2-2006. By the date of Ex. B7 the deceased was suffering from heart aliment, diabetes and hyper tension as shown in Ex. B4 and B5. So before taking housing loan the deceased was suffering from the said diseases as on 10-5-2005.

The housing loan was availed on 8-2-2006. Therefore, knowing fully well about his health condition that too suffering from heart aliment, diabetes and hyper tension, the deceased suppressed the facts and availed the housing loan and hence, the opposite parties have decided to repudiate the claim. The Xerox copy of the repudiation letter was Ex. B8. There was likelihood of putting signatures in attendance register subsequently on 10-5-2005 and 8-2-2006 by the deceased in Ex. A12 and Ex. A13. On that basis Ex. A10 and A11 might have obtained for the claim. As per Ex. B4 the deceased took treatment on 20-5-2005 also.

12. Therefore, the deceased Kesavulu suppressed the material facts of his health, but availed the loan. Thus there was no deficiency of service on the part of the opposite parties. The opposite parties proved the repudiation by way of Ex. B4 and B5. There was no contrary evidence from the complainant for Ex. B4 and b5 and there was no proper documentary proof from the complainant that the deceased was in good heath on the date of availing the loan. Thus the points are answered accordingly.

2. The brief facts of the complaint is as follows:- The husband of the complainant by name late Sirasani Jogi Reddy had taken one life insurance policy SHRI RAKSHA with double benefit on his life for Rs. 2,00,000/- from R4 vide policy No. NP 080600046866.

This policy was commenced from 16-5-2006 late S. Jogi Reddy nominated his wife i.e. the complainant as his nominee to the above policy. The insured has remitted Rs. 24,450/- towards annual premium of the policy along with accident rider and FIB rider. As per the terms of the policy, in case of death of the insured at any time during the premium term, the nominee would be entitled to receive double assured sum including vested bonus. The insured paid 2nd year premium of Rs. 24,634/- on 18-6-2007 to R4 by way of D.D. and obtained receipt.

The husband of the complainant was admitted in ESI hospital, Hyderabad due to ill health on 16-7-2007 with the complaint of cellulites and fracture of right leg. He died on 24-7-2007 due to cardio respiratory arrest. The complainant made a claim to the respondents by furnishing all documents as required by them. But the complainant received repudiation letter dt. 17-3-2008 from R2. In the said repudiation letter R2 stated that the claim of the complainant was repudiated on the ground of in correct information about pre-existing health problems of the insured. Immediately, the complainant approached R4 and requested him to settle her genuine claim.

But there was no response from him. Having vexed with the negligence attitude of the respondents. The complainant got issued a legal notice dt. 10-6-2008 calling upon the respondents to pay double amount of sum assured. For which R1 issued a reply notice dt. 3-7-2008 alleging that insured was known patient of hyper tension with cellulites left leg and he suppressed the same at the time of taking policy. The insured had suffered from hyper tension and cellulites just before one month of his death and he came to know; that he had that disease only after investigations made by ESI hospital, Hyderabad.

The husband of the complainant had no intention to deceive respondents by this it is crystal clear that the insured had no knowledge about disease prior to taking of above insurance policy. Hence, the question of non-disclosure of pre-existing disease does not arise. Without any basis the respondents alleged that the insured had a history of hyper tension with cellulites. Before accepting the proposal of the insured i.e. late S. Jogi Reddy the respondents called for special medical reports of the insured. After thorough medical examinations and obtaining its repots, the respondents company had issued insurance policy for an amount of Rs. 2,00,000/- on the life of insured i.e. late S. Jogi Reddy husband of the complainant.

The husband of the complainant never suppressed any material facts, which is basis for issuance of policy. He suffered with alleged diseases only one month before his death. The insured never took medical treatment for any kind of disease prior to taking of the policy and he never suffered with such aliments prior to taking of policy as alleged by the respondents. Without application of mind, the respondents repudiated the genuine claim of the complainant. On flimsy grounds, the respondents cannot escape from their liability from settling the claim of the complainant. The services of the respondents are deficient in nature.

Hence, the complainant filed this complaint requesting this forum to allow the complaint and to pass orders in favour of the complainant directing the respondents a) to pay Rs. 4,00,000/- (Rs. 2,00,000/- + Rs. 2,00,000/-) towards double benefit assured amount together with vested bonus under policy No. NP 080600046866 along with 24% interest from the date of death of the insured i.e. from 24-7-2007 till the date of realization, b) to pay compensation of Rs. 50,000/- for causing physical stain and mental agony and c) to pay Rs. 2,000/- towards the cost of the complaint.

3. R1 filed a counter stating and denied all the allegations put forth in the complaint, except which are specifically admitted here and the averments which are not specifically admitted herein are deemed to be denied and the complaint is not maintainable either on facts or at law and the same is liable to be dismissed in limine.

The daughters of the deceased, by name Saraswathi, is an employee of Shriram Chits (P) Ltd., at Proddatur and she arranged the subject policy in favour of her father which commenced from 16-5-2006. at the time of taking of the policy, the company has suggested the deceased to fill the proposal form with correct details regarding his health condition, pre-diseases, if any, habits etc., as required under the questionnaire of the proposal form. Basing on the information provided in the proposal form only, the company has issued the subject policy in favour of the deceased in utmost good faith. The deceased has nominated his wife, Adminarayanamma as his nominee under the policy. Through a letter dt. 12-11-2007, the complainant has intimated the company that her husband / policy holder died on 24-7-2007 at ESI Hospital, Hyderabad. On that, the company has supplied concerned claim forms to her for processing the claim.

However, it is an early death claim; and the company has conducted its regular investigation into the matter through their investigator, G. Rama Murthy, Hyderabad. The investigation has revealed that the deceased was a known patient of Hyper tension with Cellulites (left leg) and further he was a patient of HIV positive which were not disclosed by the deceased policy holder at the time of taking of the policy. It is submitted that had the company been informed about the said pre-health problems before taking the policy, the same would not have been issued by the company.

The primary duty of the proposer while taking the life insurance policy is to disclose about his / her health conditions, pre-disease, if any, habits of the life proposed for insurance. As the deceased, Sirasani Jogi Reddy has deliberately suppressed the material facts which were suppressed to be disclosed at the time of taking the policy, the contractor has now become void, unenforceable and not legally binding on the company. Therefore, the company is not liable to pay any amount towards policy claim and other benefits. The company vide its letter dt. 4-6-2009 has applied to the ESI Hospital under RTI Act to provide the entire medical records pertaining to the treatment taken by the deceased policy holder.

The Hospital authorities vide their letter dt. 4-7-2009 had intimated to the company that the deceased life assured was first time admitted into their hospital on 25-6-2007 and discharged on 14-7-2007 again he was admitted on 16-7-2007 and expired on 24-7-2007. But they have not provided any medical records as requested and upon personal interaction by one of the official of the company, the Hospital authorities have informed that they cannot provide medical records to the third parties, since it is a case of HIV related. Hence, the burden lies on the complainant to produce the entire medical record of the deceased policy holder.

The medical records submitted by the complainant itself disclose that the deceased was suffering from Hypertension with Cellulites left leg and also a patient of HIV positive. But the complainant intentionally did not speak out regarding the ailments of the deceased in her complaint and thereby tried to deviate the attention of the Hon’ble Forum. In this case some curious points are there for observation of the Hon’ble Forum at the first instance, the deceased was got admitted into ESI Hospital, Hyderabad on 25-6-2007 with complaints of cough, pedal oedema and boils over left leg and he was discharged on 14-7-2007 at the request of the patient.

The diagnosis was that he was suffering from Hypertenion, Cellulites (left leg) and HIV positive. Again, the deceased was taken to the same hospital on 16-7-2008 with the same complaints. The enquiries at the hospital have revealed that the deceased has fallen down in bath room on 18-7-2007 and received fractures to neck bone (humurus bone) and the neck of femur bone (right). But the daughter of the deceased has stated that the deceased went out of the hospital to have a tea and he was hit by an auto and received fracture injuries. Thus it was found by the investigator that the family members of the deceased are trying to suppress some facts.

It is a clear finding of the investigator that the patient/deceased has absconded from the hospital without intimating the doctors / staff on 23-7-2007 and returned by him on 24-7-2007. On routine rounds, he was found dead at 3.15 p.m on the same day. This is very unusual while the patient was treated as an in patient in a responsible hospital like ESI Hospital. One Dr. Ravi kiran has revealed before the Investigator that the deceased was a case of HIV positive. Thus there are so many facts and circumstances which were suppressed by the deceased and his family members including the treatment.

The complainant did not furnish the duly filled up claim forms which are requested by the company to be furnished by her through their letter dt. 22-11-2007. since she did not turn up, the company has sent another letter dt. 31-12-2007 and 14-1-2008 requesting her to send the same. Later, the complainant has sent the claim forms and on thorough scrutiny, the company has repudiated her claim vide their letter dt. 17-3-2008 aggrieved by the same, the complainant has got issued a legal notice dt. 10-6-2008 for which the company has issued a reply dt. 3-7-2008.

Thus in view of the above facts and circumstances, reasons, it is clear that the deceased has obtained the subject policy by suppressing the previous history of the diseases particularly HIV positive, might be under social stigma and due to fear that his status will be lowered in the eyes of his family members if the fact was disclosed. But the insurance is a contract and governed by the principal of “uberrima Fide” and the proposer applying for insurance policy is expected and bound to correctly furnish all material information regarding the health habits, family history, personal medical history etc., of the life proposed. In case of any default or hostile information, the contract will become void. Therefore, prayed the Hon’ble Forum may be pleased to dismiss the complaint against this respondent with exemplary costs in the interest of justice.

4. R3 filed a memo adopting the counter of R1.

5. R2 and R4 were called absent and set exparte on 18-8-2009.

6. On the basis of the above pleadings the following points are settled for determination.

i. Whether there is any negligence and deficiency of service on the part of the respondents?

ii. Whether the complainant is entitled to the relief as prayed for?

iii. To what relief?

7. On behalf of the complainant Ex. A1 to A9 were marked and on behalf of the respondent Ex. B1 to B11 were marked. Oral arguments were heard from both sides.

8. Point No. 1 & 2 Ex. A1 is the Xerox copy of policy bearing No. NP 080600046866 issued by the respondents in favour of S. Jogi Reddy. Ex. A2 is the Xerox copy of death certificate of the insured. Ex. A3 is the Xerox copy of repudiation letter dt. 17-3-2008 issued by R2. Ex. A4 is the Xerox copy of legal notice dt. 10-6-2008 issued by the complainant to the respondents. Ex. A5 are four postal receipts bearing Nos. 5077, 5078, 5079 and 5080. Ex. A6 are three postal acknowledgement cards.

Ex. A7 is the original reply notice dt. 3-7-2008 issued by R1 to the complainant. Ex. A8 is the Xerox coy of medical certificate of cause of death issued by ESI Hospital, Hyderabad. Ex. A9 is the Xerox coy of hospital record issued by ESI Hospital, Hyderabad. Ex. B1 is the Xerox copy of proposal for insurance submitted by the deceased S. Jogi Reddy. Ex. B2 is the Xerox copy of death intimation letter dt. 12-11-2007 sent by the complainant. Ex. B3 is the Xerox coy of letter dt. 22-11-2007 sent by the respondents company.

Ex. B4 is the Xerox copy of letter dt. 31-12-2007 sent by the respondents company. Ex. B5 is the Xerox copy of letter dt. 14-1-2008 sent by the respondents company. Ex. B6 is the Xerox copy of claim forms, A, B and C. Ex. B7 is the Xerox copy of medical reports (Ex. A9) issued by ESI Hospital, Hyderabad. Ex. B8 is the Xerox copy of medical record of Osmania General Hospital, Hyderabad. Ex. B9 is the Xerox copy of investigation report dt. 11-2-2008 of G. Ramamurthy. Ex. B10 is the Xerox coy of letter dt. 4-6-2009 sent by the respondents company to the ESI Hospital, Hyderabad. Ex. B11 is the Xerox copy of reply letter dt. 4-7-2009 of the ESI hospital, Hyderabad addressed to the respondents.

9. As could be seen from the documentary evidence the husband of the complainant by name S. Jogi Reddy had taken the policy in question on his life from R4 for a sum assured Rs. 2,00,000/- with double sum assured bonus plus vested bonus if the death occurred at any time during the premium term. This policy was commenced from 16-5-2006 and the complainant is the nominee of this policy. The husband of the complainant was admitted in ESI hospital, Hyderabad on 16-7-2007 and found dead on 24-7-2007 as per Ex. A3, repudiation letter of R2 the claim of the complainant was repudiated on the ground of incorrect information furnished by the husband of the complainant about pre-existing heath problem of the insured.

Now the question is whether the husband of the complainant suppressed the pre-existing diseases willfully which are known to him as contended by the respondents. At the time of issuance of the policy in question the age of the insured was 57 years, as such the respondent company insisted for special medical reports and after through medical examinations the special reports on his medical history was obtained by the respondents company and issued insurance policy for amount of Rs. 2,00,000/- on the life of Jogi Reddy husband of the complainant.

It was in 2006 and the commencement of the policy was on 16-5-2006. The insured as per the contention of the complainant and documentary evidence on record was admitted in the hospital on 16-7-2007 and died on 24-7-2007. As per Ex. A8 immediate cause of death of death was cardio respiratory arrest due to pulmonary enbolisam antecedent cause was hyper tension and fracture of right femur. The learned counsel for the respondents contended that the deceased Jogi Reddy husband of the complainant was known patient of hyper tension with cellulites of lift leg were not disclosed by him at the time of taking policy.

On this ground the claim was repudiated. As could be seen from the medical records i.e. Ex. B8, medical certificate of cause of death issued by ESI hospital, Hyderabad the immediate cause of death was cardio respiratory arrest and 2nd one i.e. antecedent cause of hyper tension and the last item of cause of death was fracture of right femur. So as per Ex. A8 the hyper tension is 2nd cause and cellulites left leg was the 3rd cause. The main cause of death was cardio respiratory arrest and according to the complainant this was not known to the complainant at the time of submitting proposal forms in 2006.

The contention of the complainant is supported by the version of the respondents company that the husband of the complainant under went special medical tests before acceptance of the proposals and after specifying the respondents company that the insured husband of the complainant was not having any pre-existing disease as alleged by the respondents company. The respondents company accepted the proposal and issued the insurance policy in favour of the insured husband of the complainant. The contention of the respondent that the decease like cellulites (light leg) is a typical disease that will be there in the body and it will not be known at the initial stage and to surface the symptoms of this type of diseases it consumes minimum five years of time.

Even according to the contention of the respondents the disease cellulites of right leg slowly come out and it consumes five years of time, strengthen the case of the complainant because he underwent special medical tests at the time of proposals in the year 2006 and the medical reports are silent about cellulites right leg or any other pre-existing disease. By all probabilities the complainant may not be knowing about his pre-existing diseases at the time of proposals and in view of the documentary evidence, especially medical reports particularly Ex. A8 the complainant deserves consideration in her favour. The points are answered accordingly.

This complaint is filed under Section-12 of Consumer Protection Act 1986, to pass an order in favour of the complainant directing the opposite parties to pay an amount of Rs.1,00,000/- towards the insurance benefit as per the “SBI Life – Swadhan Group” insurance scheme, to the account holder’s nominee, who is the complainant herein with interest at the rate of 12% per annum from the date of death of her husband i.e. 28.03.2008; Rs.10,000/- towards mental agony of the complainant and award costs of the complaint, and pass such other order or orders as the Hon’ble Forum may deem fit and proper in the circumstances of the case.

2. The factual matrix leading to filing of this complaint is set-out hereunder:-

a. It is the case of the complainant that the complainant’s husband by name Sri.Kathi Ramachandraiah, availed “SBI Life – Swadhan Group” insurance scheme under policy No.86000051401, bearing account No.10105214625 on 01.09.2007 and on the same day he paid the premium amount of Rs.3,643/-.

As per the terms and conditions stipulated under the scheme of the above said “SBI Life – Swadhan Group” insurance scheme, the first opposite party issued a certificate of insurance to the husband of the complainant with the sum assured of Rs.1,00,000/- bearing account No.01190/007387 commencing from the date of payment of premium i.e. 01.09.2007 and the said insurance coverage is for a period of one year. The next premium due date is 01.09.2008. As per condition No.5(a) “In the event of death of a member whilst cover is fully in force for such member, the death benefit equal to sum assured stated above, shall become payable” to the nominee of the account holder of the above group insurance scheme and the nominee of that account holder is entitled for the same.

b. The complainant further narrated in Para.2 of her complaint that the “SBI Life – Swadhan Group” insurance scheme account holder, who is the husband of the complainant was died on 28.03.2008 and his death is sudden acute myocardial infarction after complaining of chest pain. By the date of death of the husband of the complainant, the said policy was fully in force. After the death of complainant’s husband, she made representations to the 2nd opposite party dt:15.05.2008 and 23.05.2008 respectively with all necessary particulars requesting to settle the death claim policy holder i.e., Sri. Kathi Ramachandraiah account and as a nominee the complainant is entitled the benefit under the “SBI Life – Swadhan Group” insurance scheme and inspite of representations, the complainant also personally approached the 2nd opposite party and requested them on several occasions to grant the benefits, which are entitled by complainant under the above said scheme, and for which the opposite parties are postponing the same on some pretext or other.

c. The complainant further narrated in Para.3 of her complaint that inspite of several requests through requisitions and also the complainant’s personal approaches, the opposite parties are not responding to settle the benefits which are entitled by the complainant and the opposite parties wantonly neglected to settle the benefits since the date of the death of the husband of the complainant i.e., since 28.03.2008 and finally on 27.09.2008 the 2nd opposite party served a copy of letter informing that “the deceased Life Assured had given a false good health declaration at the time of entry into the scheme. The cause of death is directly attributable to the pre-existing medical condition of the deceased at the time of enrolment under the scheme, and since the policy does not cover deaths due to pre-existing illness, the claim is hereby repudiated”.

d. The complainant further narrated in Para.4 of her complaint that her husband was died causing only due to the sudden heart attack and the same was also informed to the opposite parties through her representations and the same is not considered and the opposite parties themselves confirmed that the husband of the complainant submitted the false good health certificate as if the same is submitted by the account holder. The husband of the complainant has not submitted any medical certificate on the date of joining the above said group insurance policy and the opposite parties are also not demanded to submit any medical certificate on the date of joining of the above said scheme.

There is no false representation on the date of joining of group insurance policy by the husband of the complainant and the opposite parties have no right to raise any objection at this juncture and further since the date of letter of opposite parties also the opposite parties are postponing whenever the complainant approached the 2nd opposite party by saying something without settling the death benefits of the husband of the complainant. It is purely negligence and deficiency in service of the opposite parties in providing the benefits under the above said scheme of the above said account and the opposite parties are liable to pay interest at the rate of 12% per annum along with the assured benefit which is entitled by the complainant as per the rules under the “SBI Life – Swadhan Group” insurance scheme as an account holder’s nominee.

e. The complainant also further narrated in Para.5 of her complaint that inspite of all efforts by her, the opposite parties are not turn up to settle the insurance benefits under the “SBI Life – Swadhan Group” insurance scheme and finally the complainant issued a legal notice to the opposite parties through the registered post calling upon the opposite parties to settle the death benefits of the “SBI Life – Swadhan Group” insurance scheme account holder’s assured amount to the complainant as a nominee and the same was received by the opposite parties and the opposite party No.1 gave reply notice with all false and untenable allegations only with an intention to escape their liability. The complaint is within the territorial jurisdiction of this Hon’ble Forum. Due to the negligence and deficiency of service by the respondents, the complainant is suffered a lot with mental agony and lot of inconvenience to which the opposite parties are liable to pay compensation to the complainant. Hence the complaint.

3. In response, the 1st opposite party filed written version / written statement and also an affidavit filed by one Mr. V.Srinivas, who is the duly authorized representative of S.B.I. Life Insurance Company Ltd., to represent on behalf of the 1st opposite party. As usual, the 1st opposite party narrated parawise comments for the complaint in his written version / written statement, filed on behalf of the 1st opposite party. The 2nd opposite party is adopting the written version / written statement filed by the 1st opposite party for all material aspects by filing a Memo before this Forum.

(b). The opposite parties denied the allegations made in the complaint by giving parawise comments. It is true that the contents of Para.1 are accepted to the extent that the DLA was covered under SBI Life Insurance Company’s Swadhan Group, Policy No.86000051401, account No.10105214625 for a sum assured of Rs.1,00,000/- with a date of commencement as 01.09.2007 and Certificate of Insurance was issued to him along with a summary of the major features of the Master policy stating that the conclusive document evidencing the insurance arrangement is the Master Policy Document. The rest of the contents are distorted and hence denied. It is submitted that in the event of the death of the member, the death benefit equal to the sum assured would be payable only according the terms and conditions of the policy.

The entire document should be read together and reading any particular clause in isolation is illegal and against the tenets of law. He further narrated in Para.2 of his parawise comments that the contents of para Nos. 2 and 3 are accepted to the extent that, the 1st opposite party repudiated the claim on the ground of suppression of material facts at the time of procuring the insurance cover. It is also submitted that, the DLA had concealed his pre-existing medical history of Type II Diabetes Mellitus / Hypertension and Contracted RK Diabetic nephropathy neuropathy, CK Disease and hence the claim is repudiated. The rest of the contents are denied. There is no wanton negligence on the part of the 1st opposite party. He further narrated in Para.3 of his parawise comments that the contents of Para Nos. 4 and 5 are totally denied.

(c). There is no valid ground to file this complaint before the Hon’ble Forum. It is also submitted that insurance cover was provided to the DLA based on Membership Forum. Entire reliance was placed on the information provided by the DLA in the Membership Form believing it to be true and accurate. But the DLA committed the breach of the doctrine of Utmost Good faith by concealing the fact of his pre-existing illness of Type-II Diabetes Mellitus / Hypertension and Contracted RK Diabetic nephropathy, neuropathy disease CKD. In the instant case the Membership form is the basis of contract. The DLA had declared that “have never suffered from and I am currently not suffering from diabetes hypertension” and thereby gave a false declaration of good health concealed the material facts about his health. In the instant case, the DLA had suppressed the facts about his pre-existing illness, which attributed to his death and thus the DLA committed the breach of the principle of Utmost Good Faith.

Any false information or concealment of material information would severally prejudice the interests of the Insurer. Non-disclosure of material information is fatal to the Doctrine of Utmost Good faith and thus vitiates the contract of insurance, and it is very clear from the evidence produced such as medical records that the DLA concealed the fact that he was suffering from Type II Diabetes Mellitus / Hypertension and Contracted RK Diabetic nephropathy, neuropathy, CKD Disease. As per the terms of the contract, the 1st opposite party is justified in repudiating the claim. The complainant is trying to distort the facts of the case and thereby trying to abuse the process of law. The insurance contract being a contract of UTMOST GOOD FAITH, the 1st opposite party has fully relied on the information furnished by the DLA in the Membership Form and believing the information to be true and accurate, issued the policy. The DLA is liable if the suppression of material facts is established at any point of time. The declaration signed at the end of the proposal is in the nature of a warranty and hence any breach of warranty makes the contract of insurance void ab-initio.

The policy terms and conditions and the declaration entitle the opposite party to forfeit the premiums and the opposite party need not pay any thing if the contract is vitiated by a breach of warranty. Hence the contents of Para.5 are denied. There is no deficiency in service on the part of opposite parties. The repudiation of claim is justified. There is no contractual liability on the part of opposite party to consider the insurance claim because the contract of insurance itself was vitiated by the breach of the doctrine, his pre-existing illness of Type-II Diabetes Mellitus / Hypertension and Contracted RK Diabetic nephropathy neuropathy CKD Disease. There is no negligence or deficiency on the part of the 1st opposite party. The Clause No.10 of the Schedule-III of the policy document clearly states that the insurance shall be invalid if the information furnished in any document is false or inaccurate. The clause reads: “Any insurance effected hereunder shall be rendered null and void and all moneys paid in respect of that assurance shall belong to the company, if

a) Any condition herein mentioned, or an endorsement made or by any variations evidenced by exchange of documents hereto are contravened; or

b) It is found that a statement made

- in the member date given to the company; or

- in any other document leading to the issue of the Master Policy; or

- in any other document necessary to keep the Master Policy in force.

Was in accurate, or false, or not made in good faith, or any material matter or fact was suppressed, then, and in every such case (but subject to the provision of section 45 of the Insurance Act 1938), and all claims to any benefit under this Master Policy shall cease, excepting in so far as whatever relief may be granted by law.

(d). He further narrated in Para.4 of his parawise comments that the contents of Para.6 of the complaint admitted to the extent that a legal notice dt:11.05.2009 was received, which was replied by the 1st opposite party vide reply dt:29.05.2009, explaining in detail the reason for repudiation of the claim. It is also submitted that as stated supra the decision of 1st opposite party to repudiate the claim of the complainant is just and legal, which is based on the documentary evidence produced herewith.

He further narrated in Para.5 of his parawise comments that the contents of Para.7 of the complaint are denied in toto. It is also submitted that the medical records clearly prove that the DLA was a known case Type-II Diabetes Mellitus / Hypertension and Contracted RK Diabetic nephropathy neuropathy CKD Disease. The duration of the policy was just 9 months. Thus there is a concealment of material facts by the DLA. Hence the claim has been repudiated. Thus 1st opposite party is not liable to pay any compensation to the complainant towards mental agony, inconvenience to otherwise. There is no mental agony or inconvenience caused to the complainant.

(e). He further narrated in Para.6 of his parawise comments that the complainant is not entitled to get the relief prayed and in Para.8 of the complaint in view of the facts narrated above and the documentary evidence appended herewith. It is very clear from the above paras that the claim on the life of DLA was declined as it was proved beyond doubt from the hospital records that he had suppressed the material fact that he was suffering from and a known case of Type-II Diabetes Mellitus / Hypertension and Contracted RK Diabetic nephropathy neuropathy Disease at the time of signing the membership form. Thus the claim was declaimed as the DLA has committed the breach of the doctrine of Utmost Good Faith. It is specifically denied that the complainant is eligible for the insured amount or compensation for the mental agony or harassment or costs of the complaint. The complainant is not eligible for any relief as prayed for in the complaint. He further narrated in Para.7 of his parawise comments that the complainant does not have any right or whatsoever to challenge the decision of the opposite party because the decision of the party was just and legal and no cause of action has arisen and the complainant is not entitled to file the present complaint. He further narrated in Para.8 of his parawise comments that the leave of this Hon’ble Forum to add, amend and alter the written submissions depending on the necessity and circumstances.

4. According to 1st opposite party, the facts of the case in brief, which are mentioned below as per the written version / written statement, are:-

a. That late. Sri.Kathi Ramachandraiah had submitted a Membership Form No.3659373 dt:21.08.2007 for Swadhan Group Insurance Scheme for account No.10105214825 under Master Policy No.86000051401, to the 1st opposite party through Master Policy Holder SBI, the 2nd opposite party, in which he did not reveal any adverse features relating to his health and he claimed that he was not suffering from any disease as stated in the declaration of good health.

b. That on the basis of his joining form and relying on his declaration of good health, he was covered under the said Master Policy with Date of Commencement as 01-09-2007 for a sum assured of Rs.1,00,000/- and a Certificate of Insurance was issued to him. Copies of Master Policy and Certificate of Insurance are appended as Annexure ‘A’ and ‘B’.

c. Sri. Kathi Ramachandraih is reported to have died on 28.03.2008 and death claim has been declined by the company as the DLA Sri.Kathi Ramachandraiah had concealed the material facts about his health and the decision taken was intimated to the Master Policy Holder 2nd opposite party with a copy to the complainant vide letter dt:27.09.2008. Copy is enclosed as Annexure-C.

d. That in the process of investigation of the death claim, it was revealed that late. Sri.Kathi Ramachandraiah was suffering from Type-II Diabetes Mellitus / Hypertension and Contracted RK Diabetic nephropathy neuropathy since 2000 and was also suffering from CKD and was taking treatment for the said disease prior to the date of declaration of good health. However, in the DGH he had declared that “have never suffered from and I am currently not suffering from diabetes hypertension…” and thereby concealed the material facts about his health. In this manner he suppressed the material facts in the DGH at the time of taking insurance cover. Copy of DGH (Membership form) is enclosed as Annexure-D.

e. It is very clearly stated in the consultation sheet of Rayalaseema Hospital, Tirupati, dt:24.05.2000 that DLA K.Ramachandraiah was a case of DM on insulin six months. Medical papers of Rayalaseema Hospital are appended as Annexure-E.

f. As per the Out Patient Card of Sri.Venkateswara Institute of Medical Sciences, Tirupati, dt:16.07.2005, DLA is known case of DM/HTN since 6 years and on regular treatment. As per the notes on OPD case sheet dt:14.06.2000, 17.11.2000 and 30.10.2000, 16.08.2002, 02.12.2000, it is clearly proved that the DLA was suffering from Type-2 DM/HT/Contracted RK, Diabetic nephropathy neuropathy and was taking treatment for the same. Out Patient Cards of Sri Venkateswara Institute of Medical Science, dt:16.07.2005, 14.06.2000, 17.11.2000, 30.10.2000, 16.08.2002 and 02.12.2000 are appended as Annexure-F1, F2, F3, F4, F5.

g. That the Out Patient Service sheet of Sri Ramchandra Hospital, Chennai, of November, 2000 clearly states that DLA is on medication for Diabetic Hypertension (Annexure-G1) Captopril Renogram Study of DLA Ramchandraiah dt:15.11.2000, done by Department of Nuclear Medicine of Sri.Ramchandra Hospital, Chennai, revealed Diabetic Nephropathy, Report of Sri Ramchandra Hospital, is appended as Annexure-G2.

h. The medical reports available from Eye Care Centre, Tiruapti, Ophthalmic Prescription dt:08.11.2002 to 08.12.2002, state that the DLA was known case of Diabetic since 3 years and hypertension since 2 years. Medical papers of Eye Care Centre are appended as Annexure-H.

i. The Prescription card dt:26.08.2002 of Balaji Institute of Surgery also speaks about DLA suffering from DM. Copy is appended as Annexure-I.

j. It has been clearly stated in the medical papers of Manasa Kidney Foundation, Dialysis Unit and Hypertension Clinic, Tirupati, dt:07.07.2005 and 03.05.2007, that DLA was a case of Type-II DM(5 years), HTN (3 years) and that the DLA was also detected for Chronic Kidney disease and was under treatment for the same. Copies are appended as Annexure-J1 and J2.

l. As per the Medical Attendant’s certificate and Medical Certificate, the cause of death is Acute Myocardial Infarction and Acute chest pain. Again it is clear that the cause of death is directly attributable to the pre-existing medical condition of the DLA, which the DLA had suppressed while signing the proposal form. A copy of the Medical Attendant’s Certificate and Medical Certificate are appended as Annexure-L and M.

m. From the facts stated in above Paras.4,5,6,7,8,9,10,11and 12 supra and medical papers it can be easily seen that the DLA was suffering from Type-II Diabetes Mellitus / Hypertension and Contracted RK Diabetic nephropathy, neuropathy, CKD disease but the DLA suppressed the facts about his medical condition and thereby violated the principle of Utmost Good Faith. The DLA Sri.Kathi Ramchandraiah was very much aware of his pre-existing illness for which he was taking treatment and he suppressed the material fact while signing the DGH. Had he disclosed the same, the risk cover would not have been revived by us and we would have simply rejected the request for insurance cover. Thus the repudiation was necessitated by the suppression of material facts by the DLA. Thus no deficiency in service can be attributed to the opposite parties.

n. The DLA failed in his duties towards full disclosure in the Membership form about the material fact that he is suffering from Type-II Diabetes Mellitus / Hypertension and Contracted RK Diabetic nephropathy neuropathy, CKD and thus committed the breach of the doctrine of UTMOST GOOD FAITH. Under the Contract of Utmost Good Faith, in life insurance contracts, the Life Assured should reveal not only the truth but the entire truth. The DLA has obviously failed in his duties to disclose. Thus the repudiation of claim is just and legal.

o. In the Membership Form the DLA had declared that “I hereby declare and agree that the foregoing declaration has been given after fully understanding the same and is true and complete to the best of my knowledge and that I have not withheld any information. That may influence my admission to the group insurance scheme of SBI Life Insurance Co.Ltd. Further, I hereby agree that this form including the declaration shall form the basis of my admission to the group insurance scheme and if any untrue averment be contained therein, I, my heirs, executors, administrators and assignees shall not be entitled to receive any benefits under the group insurance scheme. I also agree that the company shall not be liable for any claim on account of illness, injury or death, the cause of which was known prior to approval of my request for assurance, or withheld or concealed in the above statements”. In the instant case, the DLA had suppressed the fact about his pre-existing illness which contributed to myocardial infarction which in turn contributed to his death and thus committed the breach of the principle of Utmost Good Faith.

p. In this background, the SBI Life Company Ltd., is fully justified in repudiating the claim which has been obtained by the DLA by giving the false declaration of good health that he is not suffering from diabetes, hypertension, thereby obtaining the said Insurance cover under the said policy fraudulently.

q. The 1st opposite party has repudiated the claim because of the suppression of material fact by the Deceased Life Assured and hence the repudiation of claim is lawful and just.

r. Under Section-45 of the Insurance Act, 1938, the insurer will have to prove the suppression of material fact in case he repudiates the claim after two years from the date of commencement of the policy, if the repudiation is within two years it is sufficient for the insurer to repudiate a claim if he can establish the suppression of a fact whether it is material; or not. In the instant case, the death occurred within two years (after 8 months 29 days). It would be sufficient for the opposite party to prove the suppression of a fact for repudiation of the claim. However the 1st opposite party has strong documentary evidence that there was not only a suppression of a fact but also the facts suppressed were of material nature. Thus the action of the 1st opposite party is just and legal and had the sanction of the Insurance Act, 1938. Thus the complaint deserves to be dismissed.

s. The 1st opposite party stated that the relief prayed for in the complaint is unjust, illegal and unfair on the part of the complainant and the present complaint is frivolous, vexatious and is an abuse of the process of law. Hence, it is humbly prayed that this Hon’ble Forum be pleased to dismiss the complaint with costs to the company.

5. In support of the averments made in the complaint, the complainant filed her affidavit and also filed 9 documents, which are marked as Exs. A1 to A9. Ex.A1 is the xerox copy of certificate of insurance issued by the authorized signatory on behalf of the 1st opposite party to the complainant; Ex.A2 is the xerox copy of representation dt:15.05.2008 submitted to Group Insurance for Account holders of State Bank Group Branches by the complainant; Ex.A3 is another xerox copy of representation dt:23.05.2008 by the complainant; Ex.A4 is the original certificate dt:11.06.2008 issued by the Employer of the deceased K.Ramachandraiah filed by the complainant; Ex.A5 is the medical certificate issued by the Harshitha Hospital to the deceased K.Ramachandraiah; Ex.A6 is the original Death Certificate dt:02.04.2008 issued by the Grampanchayat, Perumallapalli, in the name of the deceased K.Ramachandraiah; Ex.A7 is the office copy of legal notice dt:11.05.2009 issued by the learned counsel for the complainant to the opposite parties. Ex.A8 is the reply notice dt:29.05.2009 issued by the 1st opposite party to the complainant, and Ex.A9 is the xerox copy of letter dt:27.09.2008 by the 2nd opposite party repudiating the claim of the complainant.

6. In support of the averments made in the written statement / written version filed by the 1st opposite party, he has also filed 13 documents, which are marked as Exs.B1 to B13. Ex.B1 is the xerox copy of Master Policy issued by the 1st opposite party and attested by an official on behalf of the 1st opposite party; Ex.B2 is the Certificate of Insurance issued by the 1st opposite party in the name of the account holder deceased K.Ramachandraiah; Ex.B3 is the xerox copy of letter of repudiation addressed to the complainant by the 2nd opposite party; Ex.B4 is the xerox copy of Group Insurance Scheme Membership Form issued in the name of deceased K.Ramachandraiah, by the 2nd opposite party; Ex.B5 is the medical prescription issued by Dr.B.Sukumar, on behalf of Rayalaseema Hospitals to the deceased K.Ramachandraiah; Ex.B6 is the xerox copies of bunch of Out Patient Cards issued by SVIMS, Tirupati, in the name of the deceased K.Ramachandraiah; Ex.B7 is the xerox copy of Out-Patient Service record dt:15.11.2000 issued in the name of the deceased K.Ramachandraiah by Sri.Ramachandra Hospital, Chennai; Ex.B8 is the xerox copy of medical prescription dt:08.11.2002 in the name of the deceased K.Ramachandraiah by Dr.J.S.Reddy on behalf of Eye Care Centre, Tirupati; Ex.B9 is the xerox copy of medical prescription dt:26.08.2002 in the name of the deceased K.Ramachandraiah, issued by BIRRD Hospital, Tirupati; Ex.B10 is the xerox copy of medical prescription dt:07.07.2005 issued in the name of the deceased K.Ramachandraiah by Manasa Kidney Foundation, Tirupati; Ex.B11 is the xerox copy of the record of medical prescription and Lab reports dt:31.12.2005 and also in the year 2006 issued by Gayathri Hospitals, Tirupati; Ex.B12 is the xerox copy of Medical Attendant’s Certificate issued in the name of the deceased K.Ramachandriah by Dr.S.Harinatha Reddy, on behalf of Harshitha Hospital, Tirupati., and Ex.B13 is the xerox of medical certificate issued in the name of deceased K.Ramachandraiah, by Harshitha Hospital, Tirupati.

7. The complainant filed her written arguments in support of her case. The opposite parties are also filed written arguments in support of their case. Both of them have filed their affidavit evidence respectively.

8. On the basis of pleadings and documentary evidence of both the sides, the following points that arise for our determination are namely:-

1. Whether there is any deficiency in service on the part of opposite parties towards the complainant?

2. Whether the complainant is entitled to the reliefs as prayed for? If so, to what extent?

3. To what relief?

9. Point No.1:- (a) There is no dispute about the obtaining of policy between the parties. The complainant has filed a detailed affidavit reiterating the facts set-out in the complaint. The opposite parties are also filed a detailed affidavit by way of evidence reiterating the facts mentioned in their written statement / written version. The learned counsel for the complainant Sri.Y.K.V.Arjuna Reddy has vehemently argued that the SBI Life – Swadhan Group insurance scheme account holder, who is the husband of the complainant, was died on 28.03.2008 and his death is sudden acute myocardial infarction after complaining of chest pain. On the date of death of the husband of the complainant, the said policy was fully in force.

His further contention is that after the death of the husband of the complainant, the complainant herein had made representations to the 2nd opposite party dt:15.05.2008 and 23.05.2008 with all necessary particulars requesting to settle the death claim policy holder and as a nominee, she is entitled the benefit under the SBI Life Swadhan Group Insurance Scheme and she personally approached the 2nd opposite party and requested on several occasions to grant the benefits, which are entitled by her under the above said scheme for which the opposite parties are postponing the same on some pretext or other. As per the terms and conditions stipulated under the above said scheme and in particular condition No.5(a) “In the event of death of a member whilst cover is fully in force for such member, the death benefit equal to sum assured stated above shall become payable” to the nominee of the account holder.

The learned counsel for the complainant further argued that the complainant’s husband was died due to sudden heart attack and the same was also informed to the opposite parties through complainant’s representations and it is not considered by the opposite parties and confirmed that the husband of the complainant submitted the false good health certificate as after the same is submitted by the account holder, the husband of the complainant has not submitted any medical certificate on the date of joining in the above said group insurance policy and the opposite parties are also not demanded to submit any medical certificate on the date of joining in the above said scheme.

There is no false representation on the date of joining of group insurance policy by the husband of the complainant and the opposite parties have no right to raise any objection at this juncture and it is purely negligence and deficiency in service on the part of the opposite parties and the opposite parties are liable to pay interest as on the date at 12% per annum along with assured benefit, which is entitled by the complainant as per the rules under the SBI Swadhan Group Insurance Scheme as an account holder’s nominee. He also further argued that the first opposite party while submitting written statement / written version alleged that the complainant knowing fully well the DLA has concealed and suppressed the material facts at the time of procuring insurance policy from them and further DLA committed fraud with an intention to obtain the insurance cover by suppressing history of his pre-existing deceases which were very well within his knowledge and thus in terms of Section-17 of Indian Contract Act 1872 the contract is void and as per Section-45 of the Insurance Act 1938, the insurer has to prove the suppression of material facts only when a policy is called in question after 2 years from the date of on which it is affected and thus in this case the death claim is within 9 months only and the repudiation action has been taken within two years from the date on which the policy was affected. He also further argued that the complainant’s husband was an employee and he has done his job till his death.

The employer of the deceased complainant husband issued a certificate (Ex.A4) stating that account holder i.e. the deceased husband of the complainant K.Ramachandraiah was not availed any sick leave during the period from 01.09.2004 to 01.09.2007 and further the Doctor, who treated him has given a certificate (Ex.A5) stating that he died due to sudden acute myocardial infarction after complaining of chest pain. As per the above said two documents (Exs.A4 and A5), the husband of the complainant had not taken any treatment for any type of ailment as he was hale and healthy till his death. All the documents are created by the opposite parties only for the purpose of the case. The other annexures J to K are also concocted documents. He further alleged that if really the husband of the complainant suffered as alleged by the opposite parties, it is impossible to attend his duty on those particular dates as he was treated by the Doctors. So, it is clearly goes to show that the opposite parties created all those documents and the same is not relating to the husband of the complainant and on this ground alone, the opposite parties are liable to pay all the benefits as per S.B.I. Life – Swadhan Insurance Scheme.

(b). The above said learned counsel for the complainant cited the judgment reported in AIR 2009 (NOC) 1804 (NCC) Consumer Protection Act (68 of 1986) Section-2(1) (g) Deficiency in service by Insurance Company – Complainant had taken life insurance policy after getting attracted with the ‘brochure’ which was in Hindi language – Policy lapsed for non-payment of premium and later on it was revived after paying premium for lapsed period – Complainant thereafter suffered paralytic attack- He would be entitled to benefits of policy – Repudiation of claim on ground that ailment episode has occurred within one year of revival date / renewal of policy – improper since said ground was not incorporated in brochure-Said ground was mentioned in policy in English language which was not explained to complainant.

10. In response, the learned counsel for the opposite parties Sri.L.Madhusudhan Reddy, has also vehemently argued that the deceased life assured i.e. namely Kathi.Ramachandraiah, is purely guilty of suppressing and concealing the material and true facts at the time of signing the Membership form with Declaration of Good Health for procuring insurance policy of the opposite parties. He also further argued that as per Section-45 of the Insurance Act, 1938, the insurer has to prove the suppression of material facts only when a policy is called in question after two years from the date on which it is affected. In the instant case, the policy resulted into the death claim within 9 months only and the repudiation action has been taken within 2 years from the date on which the policy was affected. Thus there is no need for the opposite party No.1 to prove the ingredients of Section-45 in the sense that the insurer, SBI Life in this instant case, need not prove the suppression of material facts. However, the 1st opposite party has put enough documentary evidence on record to prove the suppression of material facts. Also the cause of death is directly related with the pre-existing illness.

Thus no violation of Section-45 of the Insurance Act, 1938 is caused. Hence the repudiation action is just and legal as per the terms and conditions of the policy and is well within the scope of Section-45. The counsel for the opposite parties further argued that the DLA died on 28.03.2008 and death claim has been declined by the company as the DLA Sri.K.Ramachandraiah had concealed the material fact about his health and the decision taken was intimated to the Master Policy Holder the 2nd opposite party with a copy to the complainant. He further argued that the DLA was suffering from Type-II Diabetes Mellitus / Hypertension and Contracted RK Diabetic nephropathy neuropathy since 2000 and was also suffering from CKD and was taking treatment for the said diseases prior to the date of declaration of good health. However, in the DGH he had declared that “have never suffered from and I am currently not suffering from diabetes hypertension” and thereby concealed the material facts about his health. In this manner he suppressed the material facts in the DGH at the time of taking insurance cover. The learned counsel for the opposite parties further argued that in the Membership Form the DLA had declared that “I hereby declare and agree that the foregoing declaration has been given after fully understanding the same and is true and complete to the best of my knowledge and that I have not withheld any information. That may influence my admission to the group insurance scheme of SBI Life Insurance Co. Ltd. Further, I hereby agree that this form including the declaration shall form the basis of my admission to the group insurance scheme and if any untrue averment be contained therein.

I, my heirs, executors, administrators and assignees shall not be entitled to receive any benefits under the group insurance scheme. I also agree that the company shall not be liable for any claim on account of illness, injury or death, the cause of which was known prior to approval of my request for assurance, or withheld or concealed in the above statement”. In the instant case, the DLA had suppressed the fact about his pre-existing illness which contributed to myocardial infarction which in turn contributed to his death and thus committed the breach of the principle of Utmost Good Faith. Hence, the complainant is not entitled to get any benefits as prayed.

11. The counsel for the opposite parties cited decisions in support of his case, Hon’ble Supreme Court in the case of Chackochan vs. LIC of India (2007 x AD(S.C) 429, Civil Appeal No.5322 of 2007) has clearly held that the Insurer is justified in repudiating a claim wherever there is a suppression of material fact. In the light of the above judgment this complaint deserves to be dismissed in limine. He also cited the decision in the case of Sealark Vs. United India Insurance Co. Ltd., A Bench of the Hon’ble Supreme Court comprising justices S.B.Singh and Harjit Singh Bedi, in a recent judgement, has made it clear that if a customer fails to furnish necessary particulars while applying for the policy, the company cannot be held liable for non-payment of money. “Where there has been a suppression of fact, acceptance of the (insurance) policy by an officer of the insurance company would not be binding upon it”. The court said. Since the terms of the contract of insurance are being governed by the provisions of a statue. Non-disclosure of such material facts would render the policy reputable. It added. In view of this latest judgment, the complainant deserves to be dismissed without any further proceedings. The counsel for the opposite parties further argued that the complainant has no locus to submit that the DLA had signed the blank form. This is an afterthought. The complainant has not raised this objection earlier either in the legal notice or in the complaint. In any case, a person who has signed the document is responsible for the contents of the same.

The complainant cannot take shelter of the ignorance of the person who is not alive. He also further cited a decision in Revision Petition No.2005 of 1999 reported in 2005 (2) ALT 17 (NC) (CPA), the Hon’ble National Consumer Disputes Redressal Commission, New Delhi, has quoted that “Supression of Material Fact – Supression of Material Fact at the time of filling up proposal form for obtaining insurance policy entails disentitlement of the claim”. In the present case also the DLA suppressed the material fact about his pre-existing illness and declared that he is not suffering from diabetes, hypertension, have not taken any treatment, as stated in the DGH.

However, medical records amply proves that he was suffering and was under treatment for Type-II Diabetes mellitus / Hypertension and Contracted RK Diabetic nephropathy neuropathy since 2000 and was also suffering from CKD and was taking treatment for the said diseases prior to the date of declaration of good health. Hence the DLA had suppressed the material fact. Hence, complainant is not entitled to receive any claim. He also cited another decision in the Hon’ble National Commission in Panni Devi Vs. LIC (III (2003) CPJ 15 (NC) held that due weight should be given to the statement recorded in the normal course of discharge of one’s duties. Hence the hospital records should be treated as authentic and reliable evidence. The counsel for the opposite parties further argued that the difference in the spelling of the DLA in Annexure F, G and H, seems to have been written inadvertently, however the address of the DLA is correct in Annexure G1. The spelling in the English language depends on how a person pronounces it and there could always be confusion in recording the name in English when the name is pronounced in Telugu or other language. Such variations in spelling are not uncommon.

For example, the name Murthy is sometimes written as Murty and some times as Moorthy and so on. It does not mean that just because a syllable is missing or added, the identity of the person becomes questionable. Spelling error in the name of the DLA can also be seen in the Medical Certificate issued by the Harshitha Hospital also, regarding the death of the DLA. In that case, should we not accept that the DLA has expired on 28.03.2008?. He also further argued that the medical record has been procured during the investigation of the case. The copy of investigation report is appended herewith as Annexure-Z. During the investigation process the complainant also has admitted the fact of pre-existing illness of the DLA. The complainant is trying to mislead the Hon’ble Forum and trying to abuse the process of law by making false allegation on the 1st opposite party.

He further argued that the life of DLA was declained as it was proved beyond doubt from the hospital records that he had suppressed the material fact that he was suffering from and a known case of Type-II Diabetes Mellitus / Hypertension and Contracted RK Diabetic nephropathy neuropathy Disease at the time of signing the membership form. He further argued that the complainant is challenging the documents submitted by the 1st opposite party. It requires a thorough investigation and examination and cross-examination of witnesses which are beyond the purview of the Hon’ble District Forum. Only Civil Courts are competent to handle such cases because the proceedings before a District Consumer Forum are summary in nature.

That in the case of Life Insurance Corporation of India Vs. Surinder Kaur & Others (Civil Appeal No.5334 of 2006, SLP (C) No.7865-7866 of 2005), the Hon’ble Supreme Court of India has made it clear that “Jurisdiction of Consumer Forum can be invoked only in case where there has been deficiency of service on the part of the insurer. The claimant should have filed a suit and in a regular proceeding the matter could be gone into”. Hence it is prayed that the complaint be dismissed for want of jurisdiction. The counsel for the opposite parties further argued that the complainant is not eligible for the insured amount or compensation for the mental agony or harassment or costs of the complaint. The complainant is not eligible for any relief prayed for in the complaint. It is specifically denied that there is deficiency in service on the part of 1st opposite party.

12. Forum Observations:-

(a).We have carefully gone though the relevant record and have heard learned counsel for both parties at great length. Parties have led evidence by means of affidavits but largely relied upon the documents. The complainant has filed 9 documents which are marked as Exs.A1 to A9 where as the opposite parties have also filed 13 documents which are marked as Exs.B1 to B13.

There is no dispute about issuing of certificate of insurance (Ex.A1) to the complainant herein by the 1st opposite party. Ex.A1 and Ex.B2 are one and the same. Ex.B5 to B11 are the documents relating to the medical prescriptions issued in the name of the deceased husband of the complainant by the concerned hospital authorities prior to the date of obtaining the policy of insurance. It is true that the complainant’s husband had obtained the policy of insurance on 01.09.2007 and on the same day he paid the premium amount of Rs.3643/- to the opposite parties. Ex.B11 is the document relating to the deceased husband of complainant K.Ramachandraiah which is issued by the concerned hospital on 31.12.2005 and it is a bunch of medical record which goes to show that the deceased husband of complainant underwent different tests for his disease of Type-II diabetes mellitus and medical prescription by the doctor.

It is crystal clear from the evidence produced as medical records, the deceased husband of the complainant concealed the fact that he was suffering from Type-II diabetes mellitus / hypertension and contracted R.K.Diabetic nephropathy, neuropathy, CKD Disease. It is clearly appears that the complainant is trying to distort the facts of the case. In this consumer case, the deceased husband of the complainant while obtaining a policy of insurance from the opposite parties, had concealed the material facts about his illhealth and suppressed the facts about his pre-existing illness, which attributed to his death. It is clearly proved by the documents i.e. medical prescription and lab record. So, any false information or concealment of material information would severely prejudice the interest of the insurer. Non-disclosure of material information is fatal to the doctrine of Utmost Good Faith and so it vitiates the contract of insurance.

13. The contention of the learned counsel for the complainant with regard to applicability of the decision referred above by him to the facts of his consumer case, are entirely different to the facts of the case. It is of no helpful to him.

The position of law about basics of insurance is well-settled. Insurance, generally, is a contract of indemnity between the insured and the insurer, where the insurer promises to indemnity the insured against the loss which may sustain due to a particular risk which is covered under the policy. Insurance is a contract of good faith and both the parties the insured and the insurer have to disclose all the necessary facts within their knowledge to each other. In every case the terms and conditions of the policy would have be looked into and only if the claim falls within the terms and conditions the compensation would be paid. The terms and conditions of the policy will have to be perused and each case will have to be decided on merits and on facts and circumstances of the case.

The learned council for the opposite parties, cited decisions in support of his case about the aspect of suppression of material facts issue. It is quite correct and rule of law quoted in these decisions are binding and it is valid. In a recent decision of our Apex Court in the case of National Insurance Company. Ltd. Vs. J. Maheswaramma which is reported in (2009 CTJ 827) held that the breach of policy condition has to be proved by the Insurance Company and it is very clear that the burden of proof is on them. So, in this consumer case, the opposite parties are able to produce several documents which clearly go to show that the deceased husband of the complainant had already pre-existing decease at the time of obtaining of policy from the opposite parties, and concealment of it, is definitely vitiates the contract of insurance. It is a fraudulent act of the complainant’s husband. The person, who seeks equity from the court, must come to the court with clean hands for an appropriate relief. But herein, the complainant has not produced relevant material for our consideration to consider her case. The opposite parties are rightly repudiated the claim of the complainant after considering the material on record. There are no merits in this complaint to consider it. Hence, there is no deficiency in service on the part of the opposite parties towards the complainant. This point is answered accordingly.

14. Point No.(2):- In view of the facts and circumstances of the case discussed above in point No.1, it can be said that the complainant is not entitled to any relief as prayed for in the complaint.

clame of hart attek is not given by SBI in under Personal Accident Insurance

dear sir
i m mayur bhawsar.i m the son of mr . mohan lal bhawsar.
my father is dead by hart attek.i have the clame of hart attek is not given by SBI in under Personal Accident Insurance. sir plese give me some suggestion.....
plese sir

This is a complaint filed Under Section 12 of the Consumer Protection Act, 1986 (hereinafter called as Act for short)

2. Through this complaint, the complainant prays for an award and order against the Opposite Parties (hereinafter called as the OPs for short) to pay the assured amount of Rs.1,87,500/- and to benefits as per the terms and conditions of the policy; Rs.3,00,000/- towards the compensation for mental agony, accident benefit and costs of the proceedings.

3. The facts given rise to institute the complaint may be summarized as thus:

It is contended that, the complainant’s husband by name Shivaraju.L, had taken an insurance policy from the OPs. The said policy bearing No.23024967305 and it is Horizan II Plan policy. As per the schedule of the premium in the said policy, the OPs have collected a sum of Rs.25,000/- and the sum assured was Rs.1,87,500/- alongwith benefits as per the terms and conditions of the policy. Thus, the OPs are liable to pay a sum of Rs.1,87,500/- being the sum assured to the nominee. The complainant’s husband Shivaraju, died on 23-3-2009 in a motor accident. A case was registered by the jurisdictional police under crime No.09/2009 and also informed the OPs orally on the date of accident. On the basis of information, the OPs have sent their surveyor and surveyed the accident as per the rule. But the OPs have not taken any steps for payment of assured amount as per terms and conditions of the policy. On 27-8-2009 the complainant had issued a legal notice to the OPs and same was served on the OPs No.2 and 3, but the notice issued to the 3rd OP was not returned. But unfortunately, since from the date of receipt of legal notice, they have not cared to issue even single information. Inspite of repeated requests and demands made by the complainant orally and in writing, they went on dodging the payment on one or the other pretext and they failed to discharge their bounden duty/service to the complainant. Thus, it is alleged that, it is a specific case of deficiency of service. Evenafter service of the legal notice to the OPs, they have not chosen to pay the assured amount to the complainant. The complainant is a helpless window and her life has become miserable after accidental death of her husband. The non-payment of policy assured amount by the OPs highly deplorable. Hence this complaint.

4. The OPs, who have been notified of the complaint, put in their appearance through their counsel and resisted the same by filing common objections.
5. The gist of the OPs objections are as follows:

In the common objections filed by the OPs, it is alleged that, the complaint is premature and hence it should be dismissed without further proceedings, because the OPs have not received any claim intimation from the complainant. The OPs have not received any documents such as death certificate, claim form, original policy bond etc from the complainant, which are sine-qua-non to process the claim to examine its admissibility or otherwise. Hence it is prayed before this forum to advise the complainant to submit the relevant documents to the OPs. On receipt of the legal notice, the OPs have called for the documents in support of the claim, which have not been submitted so far by the complainant. Further the policy is in lapsed condition as on date of the death of insured and hence nothing is payable under the policy. As there was no cause of action, the complaint is not maintainable and there is no deficiency in service on the part of the OPs. Hence the complaint is liable to be dismissed in limine. Accordingly, they pray for dismissal of the complaint with costs.

6. In support of the cases of the parties, the complainant and OPs have filed their affidavits and have also pressed into service of several documents. We have heard the learned counsels appearing for the parties. We have also examined the materials available on record.

7. The questions that arise for our considerations are:

1) Is there any deficiency in service on the part of the OPs?

2) Is the complainant entitled to the relief as prays for?

8. Our findings on the above questions are here under.

Point No.1: Negative

Point No.2: As per the order
REASONS

9. At the very threshold, we must point out that, a careful perusal of the materials produced by the parties, nothing is made out by the complainant to show that, after the accident, she had informed to the OPs through necessary documents to process her claim. It is also relevant to note that, as per Annexure-B, the OPs vide their letter dated 8th Sept. 2009 have called for necessary documents to examine the claim of the complainant. The said letter is at Annexure-B and it reads as thus:

Without Prejudice

Date: 08-Sept-09

Mrs. Indramma C R

M M A Kaval,

Chelure hobli, Tal-Gubbi,

Dist – Tumkur, Karnataka

Ref No: 9788/OP2/08-09/CL/R/4847
Policy No: 23024967305: Horizon II

Ref: Death claim of Late Mr.Shivaraju.L.

Dear Madam,

We acknowledge the receipt of legal notice dated 27-8-2009 under the aforesaid policy. We are sorry to note the unfortunate demise of Mr.Shivaraju.L and express our sympathies to you and your family members.

We have registered the claim on the basis of legal notice received.

I order to check the admissibility or otherwise of the claim at the earliest, we request you to provide us the requirements given below;

Claim Form to be filled in & signed by the nominee (with bank details) & verified by the branch manager

Original policy document

Death certificate

Yours truly,

Sd/-

Head – claims

SBI Life Insurance Company Ltd,

PH: 022-66456259

Claims@sbilife.co.in
10. The complainant has not produced any iota of evidence to show that, she had furnished those documents to enable to the OPs to process and examine the claim of this complainant. In the absence of such proof, it can not be said that, there is deficiency in service on the part of the OPs. Before filing necessary documents, the complainant appears to have this complaint hurriedly. Therefore, it is premature and no cause of action is made out. Thus, we hold that, the complaint is liable to be dismissed with a suitable direction to the complainant to produce the necessary documents to the
11. Being that opinion we proceed to pass the following:

ORDER

The complaint is dismissed with a direction to the complainant to submit relevant documents referred to Annexure-B to the OPs for processing her claim. If the documents are filed by the complainant within 30 days from the date of this order, the OPs shall examine and process the claim without any delay in accordance with law. Under the circumstance of the case, the parties are directed to bear their own costs.

Dictated to the stenographer, typed by him, corrected and pronounced on open forum this 23rd day of November 2009.

2. The brief admitted facts of this complaint are that the complainant had obtained a life insurance policy no. 14005340407 with money back benefit from OP No.2 and had paid installments to the tune of Rs.18145/- , Rs.17,870/- and Rs17,830/- on 30/09/2005, 01/03/2007 and 25/02/2008. As per terms and conditions of the policy the ops were to pay a sum of Rs.20,000/- to the complainant after payment of 3 installments. However despite the depositing of Rs.17, 830/- on 25/02/2008 the Ops failed to pay an amount of Rs.20,000/ to the complainant despite repeated requests and registered notice dated 06/06/2009. The Ops thus were stated to be deficient in service towards the complainant. Now an amount of Rs 53,845/- was claimed to be due from the Ops with interest @18 percent P.A. from the date of issuance of the policy and depositing of installment 30/09/2005 . Hence this complaint.

3. In the written version filed by the Op, the issuance of the policy as well as the condition about the payment of Rs.20,000/- as survival benefit on the due date i.e. after 3 years, was not disputed. However it was contended that the due date in the instant case was 03/02/2009 but the policy was not in force status due to shortage in premium paid by the complainant. Hence survival benefit amount was not paid to her. The shortage amount was paid by the complainant on 14/05/2009 and after processing the same, cheque no. 747930 dated 12/06/2009 for Rs 20,000/- had been dispatched to the complainant. Further it was contended that the installment premium payable was of Rs.17,915/- every year but there was shortage of Rs.9/- and Rs51/- in the 2nd and 3rd installment premium paid by the complainant. It was further contended that the policy terms and conditions do not grant refund of premium under any circumstance and as such the demand for refund of the same was untenable. A prayer for dismissal of the complaint was accordingly made.

4. Both the parties have placed on record their respective evidence in the shape of affidavits and other documents.

5. We have considered the oral submissions advanced by the ld counsel for the parties and carefully scrutinized the evidence on record.

6. No doubt the complainant has alleged that she paid the first three installment and as such was entitled to the payment of survival benefit of Rs.20,000/- after deposit of the 3rd installment on 03/02/2009 yet the perusal of the policy Ex R-2 indicates that under clause C of schedule 2, “the term assurance rider benefit” was payable subject to the terms and conditions of this policy. Schedule 3 of the Policy describes terms and conditions and as per clause 2 a grace period of 30 days was allowed for payment of quarterly/half-yearly/yearly premiums and if the premium was not paid before the expiry of the days of grace, the policy would automatically lapse. In this case, default of Rs.9/- related to the premium for the year 07 and Rs51/- for the premium of year 2008. The 2nd and 3rd installment were deposited on 01/03/2007 and 25/02/2008 respectively. The shortage amount was deposited however on 14/05/2009 i.e. beyond the expiry of the grace period of 3 months. Thus there is great force in the contention of the Ops that on the payment of 3rd installment of Rs17,830/- on 25/02/2008 the policy was in lapse condition and after the payment of deficient amount on 14/05/2009 the payment of survival benefit was processed and cheque of Rs 20,000/- was accordingly issued to the complainant on 12/06/2009. In such state of affairs the Ops can not be held deficient in service towards the complainant, in the payment of survival benefit payment. Regarding the refund of the entire installments amount, clause 4 of schedule 3 provides that the policy will acquire paid up value on completion of three years from the date of commencement of risk, provided all premiums due during the first 36 months have been paid in full. It also provides that paid up value is available only for the basic plan and not for riders. The table under this clause also describes the paid up value under different option. There is nothing on record from the side of the complainant to show that she had ever requested the Ops of the surrender of the policy and payment of paid up value. In such circumstances, the claim about the refund of entire amount of three installments is not at all tenable. .

7. In view of the aforesaid facts, the complaint is without any merit and as such is dismissed.

8. The complainant however may request the Ops in writing indicating her intention to surrender the policy and payment of paid up value, if any, to her as per terms and conditions of the policy.

Missguidence by the agent Want the money back

Plan SBI MoneyBack Option 2 Sequense no, 3745142 ,IA Code 17339803 Total premium paid is Rs.300000/- on date july 07,2009. The agent told us that we will have to deposite the instalments only for three years but when we go to the office to deposite 2nd installment we come to know that we will have to deposite the installments for 15 yrs .So we are not willing to continue this paln for such a long period .Please help us and give us any solution if want to get our faith in ur bank. Thanks
Your's notfaithfully
Mrs. Meenakshi,Policy No. 140 15592 402

PF Number is MH/BAN/49971/15063 Not Received

Dear Sir I was working with SBI Life Insurance Company Ltd as a Branch Sales Manager With their Patan Branch Gujarat. My Name Is Mr Tejas Modi My Employee code was 18408 and my PF Number is MH/BAN/49971/15063. I had Resign on 1st December 2012. But till date company has not send any mail regarding acceptation about my Resignation mail. Sir i had applied for my PF withdrawals form via Speed post dated on 24th May Consignment number EG149871898IN, Sir company is not clear my PF amount and presently i am not working any where so i need my pf so please help me in this matter.
Thanks and Regards
Tejas Modi
9825228700

Sub: Cancellation of ECS request & Aount has been Debited

Dear Sir,

This letter is to inform you that I had a surrounded my SBI Policy (SBI policy no: 18005039301) on 06/01/2012, however my ECS is getting deducted on 27th of every month.On 5th of November 2013, I had visited SBI bank (Tallakulam Branch ) to meet Manager he said we not be able to cancel the same and instead suggested me to visit the SBI life insurance office to have the same cancelled.

I then had visited SBI life insurance office – Tallakulam branch were they said that they cannot do anything from their end and again redirect me back to Branch office.
I was again forced to rush back to the SBI life insurance office – Tallakulam branch were the bank front office Coordinate left me helpless with an Mobile:9940135993( someone working at SBI life Insurance- Bypass road branch )to call and to have the issue fixed, who in turn redirected back to the bank to have the ECS cancelled.
I am not only surprised but heartbroken that your bank is making me run from pillar to post to just have my ECS cancelled which is still not resolved. Oct 27th Amount has been Debited, but Still amount is not credited in my SB Account. i send a cancellation request for two time no response from bank side & SBI Life insurance . Please have my ECS cancelled. Waiting for your valuable revert.

False Promises and Not Returning my money

Dear Madam / Sir,
I the undersigned requested for Subh Nivesh Plan for 5 years for Sum Assured 1,50,000/- with SBI Life (Attached Chart from SBI Life for your reference) vide cheque No. 418848 dated 02nd August 2013 for Rs. 30,000/- (Standard Chartered Bank, Bangalore) (Attached August’2013 Statement enclosed for your reference) for Subh Nivesh Plan (5 years). Policy was effective from 13th August 2013. Received the Policy Documents on 28th August 2013 (Policy No. Policy No. 56049725704). Called Ms. Jyoti Mobile No. 9743891160 on 28th August 2013 & told her got the wrong policy. She said tomorrow my person will come and collect the policy, but he didn’t come. I called Jyoti on 30th August 2013 she said person will come today and collect documents. Mr. Santhosh Mobile No. 8921051722 came on 30th August 2013 & collected the documents. I told Jyoti if you can’t change the policy Plan from SBI Life – Flexi Smart Insurance (Policy No. 56049725704) to Shubh Nivesh for Sum Ansured 1,50,000/- Policy Term 5 years for Existing Policy Period (i.e. 13th August 2013), then Cancel the Policy and return my money back. (Attached application & emails for your reference).
Ms. Jyoti promised me within 5 days I will get the Subh Nivesh Policy but till now I didn’t get. I was trying to reach Ms. Jyoti by mail and call, no response. Called Ms. Usha Mobile No. 9538237236 on 18th August 2013 but She is on leave, tomorrow she will tell me. Somebody called me from SBI Life, he was saying his designation as Assistant Manager Mobile Nos. 74112 68569 & 7204657102, he was saying can’t cancel my policy or change, then I told him I was telling him to cancel and return my money back but he was not ready. He was for cancelling there is a penalty, I told its not my mistake you resolve it.
I called Ms. Usha on 19th September 2013, she said she is in meeting, she will call me back, but she is not bother to call. Then again I called after 45 minutes she said we will cancel the policy, within 45 days money to be returned & give a fresh cheque of Rs. 30,000/- for Subh Nivesh policy we will issue the fresh policy. I told I don’t want any policy, just cancel the policy and return my money of Rs. 30,000/- without any deductions. I told I will meet her in her office in Malleshwaram Branch at 3.30 pm. First she refused then she agreed. When I reached SBI office Ms. Usha was there. I went to SBI personally regarding above issue, I met Mr. Thayagarajan K. Manger, he said he will try to cancel the policy, he will send the mail to higher authorities. At the end no result, all the time I have to remind them.

The aboves are working with Ms Geeta A.R. (IA Code 990209348) M : 9060050333. Kindly Cancel her licence, because she is misguiding people and help me to get the money back.

I requested sbi to cancel the policy in free look up time, but they didn’t. after that also I requested them by mail and sending policy, but they didn’t. they send me toned policy back.

For your information I didn’t fill the proposal form.

I requested many times to cancel the policy and return my money back of Rs. 30,000 at the earliest without deductions. But no use. Because of this SBI Policy waste of time, mental torture.

Let me inform you that SBI response very very bad.
So kindly look into the matter and resolve it at the earliest.